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THE    THROAT   AND  NOSE 

AND   THEIR  DISEASES, 

BEING 

A  FOURTH,    REVISED,    AND    EXPANDED  EDITION 

OF 

THE  THROAT  AND  ITS  DISEASES; 

WITH 

ILLUSTRATIONS  BY  THE  AUTHOR. 


Digitized  by 

the  Internet  Archive 

in  2015 

https://archive.org/details/throatnosetheirdOObrow_0 


THE 

THROAT  AND  NOSE, 


AND  THEIR  DISEASES, 

WITH  ONE  HUNDRED  AND  TWENTY  ILLUSTRATIONS  IN  COLOUR, 
AND  TWO'HUNDRED  AND  THIRTY-FIVE  ENGRAVINGS, 

DESIGNED    AND    EXECUTED    BY    THE  AUTHOR, 

LENNOX  BROWNE,  F.R.C.S.E., 

SENIOR  SURGEON  TO  THE  CENTRAL  LONDON  THROAT  AND  EAR  HOSPITAL, 
SURGEON  AND  AURAL  SURGEON  TO  THE  ROYAL  SOCIETY  OF  MUSICIANS, 
LATE  PRESIDENT  BRITISH  LARYNGOLOGICAL  ASSOCIATION,  ETC. 


PHILADELPHIA: 
LEA    BROTHERS    &    CO.,    SANSOM  STREET. 
LONDON  :  BAILLIERE,  TINDALL  AND  COX. 
1893. 

\.All  rights  re  served. '\ 


,  ft) -si 


THIS  WORK  IS  DEDICATED 


COMMITTEE  AND  MEDICAL  STAFF 

OF  THE 

CENTRAL   LONDON  THROAT   AND   EAR  HOSPITAL 

IN  GRATEFUL  RECOGNITION  OF  GENEROUS  SUPPORT 
AND  CORDIAL  CO-OPERATION  IN  ATTAINMENT  OF  THE  EXPERIENCE 
ON  WHICH  ITS  TEACHINGS  ARE  BASED. 


CONTENTS. 


PACK 

Titles          -         -         -         "         -         "         "          "  ^""^ 
Dedication  .-------v 

Table  of  Contents  -          -         -         -         -         -         -  vii 

Preface  to  Fourth  Edition           -         -                   -          -  xix 

Introductory'         -         --  ----i 

CHAPTER  I. 

Anatomy  and  Physiology  of  the  Throat  and  Nose      -          -          -  6 


The  larynx,  cartilages  of,  6  ;  Divisions  of,  14  ;  Ventricular  bands,  15  ;  Vocal 
cords,  15  ;  Ventricles,  16  ;  Muscles  of,  17  ;  Vessels  and  nerves,  21  ;  Mucous 
membrane,  22  ;  Trachea,  23  ;  Functions  of  larynx,  23 ;  Palate,  26  ;  Uvula, 
27  ;  Tonsils,  28  ;  Pharynx,  28  ;  (Esophagus,  32  ;  The  nose,  33  ;  Eustachian 
tube,  37. 

CHAPTER  H. 

Examination  of  the  Throat  and  Larynx — The  Laryngoscope  -  -  39 

Sources  of  light,  39  ;  Reflector,  45  ;  Mirrors,  46  ;  Laryngoscopy,  47  ;  in  chil- 
dren, 53. 

CHAPTER  HL 

Inspection  of  the  Mouth,  Fauces,  and  Pharynx  -  -  -  55 

The  teeth,  58  ;  Gums,  tongue,  buccal  cavity,  58  ;  Soft  palate,  fauces,  and  uvula, 
59  ;  Tonsils,  60 ;  Pharynx,  60. 

CHAPTER  IV. 

The  Laryngoscopic  Image      -  -  -  -  -  -  6t 

Description  of  the  various  portions  of  larynx  as  seen  in  mirror,  64  ;  In  production 
of  tone,  68  ;  The  soft  palate  in  ditto,  70 ;  Auto-laryngoscopy  and  photo- 
laryngoscopy,  72. 

CHAPTER  V. 

Examination  of  the  Nasal  Passages — Rhinoscopy — The  Rhinoscopic 

Image  -  -  -  -  -  -  -  -76 

Anterior  Rhinoscopy,  76  ;  Anterior  rhinoscopic  image,  79  ;  Posterior  rhino- 
scopy, 80  ;  Digital  examination,  84  ;  Posterior  rhinoscopic  image,  85  ;  Naso- 
pharynx. 8.7 


Vlll 


CONTENTS. 


CHAPTER  VI. 

General  Semeiology  of  Throat  Diseases  -  -  -  -  88 

A.  Functional  or  subjective  symptoms,  91  ;  Voice  and  respiration,  91  ;  Cough, 
92  ;  Deglutition,  93  ;  Nasal  respiration,  94  ;  Senses  of  smell,  taste,  and  hear- 
ings 95  ;  I'siin,  96  ;  B.  Physical  or  objective,  96  ;  Colour  and  form,  96  ; 
Mobility,  position,  and  secretion,  97  ;  C.  Miscellaneous,  97  ;  Stethoscope, 
sphygmograph,  ophthalmoscope,  pulse,  history,  weight,  temperature,  spiro- 
meter, 98. 

CHAPTER  Vn. 

Therapeutics  of  Throat  Diseases,  Medical,  Surgical,  Dietetic,  and 

Hygienic        -  -  -  -  -  -  -  100 

Gargles,  loi  ;  Lozenges,  103  ;  Inhalations,  104 ;  Vapour,  104  ;  Dry  hot, 
107  ;  Cold,  108  ;  Oro-nasal,  108  ;  Cold  air,  109  ;  Compressed  air,  109  ; 
Atomized,  109;  Sprays,  no;  Fuming,  114;  External  applications,  116; 
External  pigments,  119;  Douches  or  Collunaria,  119;  Tampons,  124; 
Internal  applications,  124 ;  Insufflations,  127;  Caustics,  128;  Bleeding  and 
scarification,  129;  Laryngeal  snares  and  forceps,  130;  Electro  Therapeutics, 
132  ;  Faradism,  134  ;  Galvano-cautery,  135  ;  Massage,  141  ;  Removal  of 
foreign  bodies,  142  ;  Tracheotomy,  142  ;  Anassthetics,  145  ;  Dietetics  and 
Hygiene,  147  ;  Artificial  feeding,  148  ;  Respiratory,  148  ;  Respirators,  149  ; 
Vocal  152;  Balneo-therapeutics,  152. 

CHAPTER  Vin. 
The  General  Etiology  and  Pathology  of  Throat  Diseases       -  -  154 

In  relation  to  the  connection  of  throat  and  nose,  154  ;  To  the  tonsils,  156  ;  To 
Micro-organisms,  158  ;  To  hyperaemia,  anaemia,  and  catarrh,  163  ;  To  consti- 
tutional states,  166  ;  To  anatomical  facts,  167  ;  To  respiration,  169  ;  To 
deglutition  and  mastication,  170;  To  voice  production,  171  ;  To  atmosphere 
and  climate,  173  ;  To  clothing,  175. 

CHAPTER  IX. 

Diseases  of  the  Pharynx         -  -  -  -  -  -  i77 

Acute  pharyngitis,  179;  Common  membranous  sore  throat,  181  ;  Suppurating 
pharyngitis — hospital  sore  throat,  184  ;  Chronic  blennorrhoea,  185  ;  Ulcera- 
tive septic  pharyngitis,  186;  Post-pharyngeal  abscess,  187;  Subacute  pharyngitis, 
190;  Chronic  pharyngitis — Clergyman's  sore  throat,  191 ;  Pharyngitis  sicca  vel 
atrophica,  193,  197  ;  Pharyngitis  lateralis  hypertrophica,  193  ;  Tobacco 
pharyngitis,  194;  Ulceration  of  the  pharynx,  200  ;  Syphilitic — Primary,  200  ; 
Secondary,  201  ;  Tertiary,  205  ;  Congenital  and  hereditary,  209  ;  Scrofulous, 
212  ;  Tubercular,  213  ;  Lupus  and  lepra  of,  222  (see  also  p.  427) ;  Neuroses 
of,  222  ;  Aneesthesia,  222  ;  Hypera;sthesia.  222  ;  Parsesthesia,  223  ;  Lingual 
varix,  223  ;  Hypertrophy  of  lingual  tonsil,  224  ;  Spasm  of  pharynx,  225  ; 
Neuralgia,  226  ;  Motor  paralysis,  227  ;  Malformations,  227  ;  Stenoses,  227  ; 
Pharyngocele,  227  ;  Deformities,  228  ;  Morbid  growths  of,  228  ;  Foreign 
bodies  in,  229. 

CHAPTER  X. 

Diseases  of  the  Uvula  -  -  -  -  -  -  231 

Inflammation,  acute,  of,  231  ;  Subacute,  232  ;  Elongation  of,  232  ;  Mallorma- 
tions  and  new  growths  of,  237  ;  Malignant,  238. 


CONTENTS. 


IX 


I'AC.E 

CHAPTER  XL 

Diseases  of  the  Tonsils  -  -  -  -  -  239 

Histology,  239  ;  Inflammation,  acute,  of — Tonsillitis,  240  ;  Chronic — Enlarged 
tonsils,  252  ;  Tonsillotomy,  256  ;  Atrophy  of,  259  ;  Mycosis,  260  ;  Benign 
growths  of,  260  ;  Cancer  of,  261. 

CHAPTER  XII. 

Diseases  of  the  Larynx  -  -  -  -  -  -  270 

Histology  of  larynx,  270;  Ansemia,  271;  Hyper?emia  and  hiemorrhages  of, 
272  ;  Classification  of  laryngeal  inflammations,  274. 

CHAPTER  XIIL 

Inflammation  of  the  Mucous  Membrane  of  the  Larynx  -  -  277 

Acute,  277  ;  Infantile,  282  ;  In  measles,  282 ;  In  variola,  282  ;  In  scarlatina, 
282  ;  In  typhoid  and  typhus,  283  ;  Subacute,  289 ;  Chronic,  289  ;  Granulosa 
vel  follicular,  291  ;  Phlebectasis  laryngea,  293  ;  Laryngitis  sicca,  297  ;  Sub- 
glottic, 298. 

CHAPTER  XIV. 

Inflammation  of  the  Submucous  Tissues  of  the  Larynx — CEdema       -  300 
Acute,  300  ;  Chronic,  308. 

CHAPTER  XV. 

Inflammation  of  the  Perichondrium  and  Cartilages  of  the  Larynx     -  311 
Varieties,  311  ;  Symptoms,  316;  Prognosis,  319;  Treatment,  319.  ' 

CHAPTER  XVL 

Exudative  or  Membranous  Inflammation  of  the  Larynx         -  -  321 

Idiopathic — Croup,  321  ;  Traumatic,  333, 

CHAPTER  XVII. 
Diphtheria  -  -  -  -  -  -  -  -  335 

Etiology — Nature  of  contagium,335  ;  The  Germ  theory,  335  ;  Ptomaine  theory, 
337  ;  Inoculability,  338  ;  Mode  of  origin,  etc.,  335  ;  Insanitary  causes,  340  ; 
Season,  340  ;  Age,  341  ;  Constitution,  341  ;  Social  status,  342  ;  Pathology 
— Anatomical,  of,  343  ;  Histological,  344  ;  Symptoms — Functional,  347  ; 
Physical,  349;  Miscellaneous,  350;  Varieties,  351;  Complication  and 
sequeloe,  352  ;  Differential  diagnosis,  352  ;  Prognosis,  course  and  termina- 
tion, 355;  Recurrence,  356;  Treatment — General,  357;  Local —Internal, 
361  ;  External,  366 ;  Dietetic,  367  ;  Operative,  368  ;  Tracheotomy,  369  ; 
Intubation,  371  ;  Hygienic  and  prophylactic,  377. 

CHAPTER  XVIIL 

Syphilitic  Laryngitis    -------  ^g© 

Secondary,  380  ;  Relapsing,  382  ;  Tertiary,  383  ;  Tracheotomy,  390 ;  Stenosis, 
391  ;  Congenital,  396. 


X  CONTENTS. 

CHAPTER  XIX. 

Tuberculous  Laryngitis 

Etiology,  402  ;  Pathology,  403  ;  Symptoms — Functional,  409  ;  Physical,  412  ; 
Miscellaneous,  414;  Diagnosis,  414;  Prognosis,  etc.,  418  ;  Treatment,  419  ; 
Tracheotomy,  424. 

CHAPTER  •  XX. 

Lupus  of  the  Mouth,  Pharynx,  and  Larynx— Leprosy  -  -  427 

Literature  of,  428;  Etiology,  431;  Symptoms,  434 ;  Diagnosis,  438  ;  Treat- 
ment, 440  ;  Lupus-like  disease,  440  ;  Leprosy,  443. 

CHAPTER  XXL 

Benign  Neoplasms  of  the  Larynx       -  -  -  -  -  447 

Etiology,  448  ;  Pathology,  452  ;  Symptoms,  453  ;  Treatment,  455  ;  Thyrotomy, 
464  ;  Tracheotomy,  465. 

CHAPTER  XXH. 

Malignant  Neoplasms  of  the  Larynx   -----  467 

General  Pathology,  467  ;  Etiology,  477  ;  Symptoms,  480 ;  Prognosis,  487  ; 
Treatment,  488  ;  Endo-laryngeal,  489  ;  Tracheotomy,  490  ;  Laryngectomy 
— complete,  492  ;  Partial,  493  ;  Thyrotomy  and  erasion,  497  ;  Sub-lingual 
pharyngotomy  498  ;  Hygienic  and  dietetic,  498. 

CHAPTER  XXHL 

Neuroses  of  the  Larynx  ^00 

Neuroses  of  sensation,  500;  Of  motion,  503;  Paralysis  in  domain  of  superior 
laryngeal  nerve,  505;  Ditto  of  inferior  laryngeal  nerve,  506;  Bilateral  paralysis, 
of  adductors,  508  ;  Unilateral  ditto,  510  ;  Bilateral  paralysis  of  abductors, 
511;  Unilateral  ditto,  513:  Paralysis  of  sphincters,  516;  Spasmodic  affec- 
tions, 515  ;  Spasm  offtensors,  517;  Spasm  of  adductors,  518;  Nervous 
laryngeal  cough,  521  ;  Epileptiform  neuroses,  522. 


CHAPTER  XXIV. 

The  General  Etiology  and  Pathology  of  Nasal  and  Naso-Pharyngeal 

Diseases  ^32 
The  nasal  mucous  membrane,  532  ;  Olfactory  region,  533  ;  Respiratory  region, 
535  ;  Normal  physiological  functions,  538  ;  Rhinitis  hypertrophica,  541  ; 
Rhinitis  atrophica,  543  ;  Polypi,  543  ;  Reflex  neuroses,  544  ;  Epileptiform 
neuroses,  54"; ;  Mania,  etc.,  546;  Stammering,  aprosexia,  etc.,  547  ;  Eye 
diseases,  548  ;  Asthma,  549;  The  accessory  cavities,  551  ;  Naso-pharyngeal 
disease — Tornwaldt's  disease,  552  ;  Adenoid  growths,  552  ;  General  charac- 
teristics of  nasal  obstruction,  553. 

CHAPTER  XXV. 

Diagnosis  and  Treatment  of  Nasal  and  Naso-Pharyngeal  Diseases      -  556 

Classification,  556;  Diseases  of  mucous  membrane — Rhinitis,  acute,  557-  ^'^ub- 
acute,  564;  Neurotic— Hay-fever,  etc.,  565;  Chronic  hypertrophic  rhinitis, 
571  ;  Varieties  of,  572  ;  Rhinoscleroma,  578  ;  Atrophic  rhinitis,  579  ;  Lupus, 


CONTENTS. 


xi 


586  ;  Lepra,  587  ;  Tuberculosis  of,  588  ;  Rhinitis  Caseosa,  588  ;  Diseases  of 
1^  Septum — Haematoma  of,  589  ;  Abscess  of,  590  ;  Perforations  of,  590  ;  Devia- 
tions and  deformities  of,  592 ;  Dislocation  of  the  Columnar  Cartilage,  608  ; 
Necrosis  and  caries,  609  ;  Synostosis,  612  ;  New  growths — Polypi,  612  ; 
Fibromata,  618  ;  Cystomata,  619  ;  Papillomata,  620;  Enchondromata,  620; 
Osteomata,  620;  Exostoses,  620  ;  Sarcomata,  621  ;  Carcinomata,  621  ; 
Schirrus,  621  ;  Epistaxis,  622;  Neuroses — Anosmia,  624  ;  Parosmia,  625  ; 
Foreign  Bodies — Rhinoliths,  626  ;  Larvae,  Fungi,  etc.,  626  ;  Diseases  of 
Accessory  Cavities— Catarrh  of  Maxillary  antrum,  626;  Empyema  of  ditto, 
•  626;  Diseases  of  frontal  sinus,  633  ;  Of  ethmoidal  cells,  633;  Of  sphenoidal 
sinuses,  634  ;  New  growths,  634  ;  Naso-pharyngeal  Cavity — Catarrh,  post 
nasal,  635  ;  Hypertrophy  of  pharyngeal  tonsil,  637  ;  New  growths,  649. 

CHAPTER  XXVL 

Aural  Maladies  associated  with  Naso-Pharyngeal  Disease. — Part  I. — 

How  to  Examine  an  Aural  Case         .  .  -  -  6^0 

Functional  and  subjective  symptoms,  651  ;  Hearing  power — Conversation,  651  ; 
Watch,  652  ;  Discharge,  652  ;  Pain,  653  ;  Tinnitus,  653  ;  Tuning-fork,  654; 
Vertigo,  654  ;  Physical  and  objective  signs,  657  ;  Membrana  tympani,  657  ; 
Tympanic  cavity,  660  ;  Mastoid  process,  660  ;  Eustachian  tube,  660  ;  New 
growths,  661  ;  Eye  affections,  661  ;  Aural  case  form,  662. 

CHAPTER  XXVn. 

Aural  Maladies  associated  with  Naso-Pharyngeal  Disease. — Part  H. — 

General  Etiology  and  Therapeutics      .  -  .  -  668 

Eustachian  tube,  668  ;  Causes  of  obstruction  of,  670  ;  Treatment  of  chronic 
non-suppurative  catarrh,  672 ;  Valsalvan  inflation,  672  :  Politzer  inflation, 
673 ;  Eustachian  catheter,  674  ;  Vapours,  675  :  Suppurative  catarrh  and  its 
consequences,  676. 


Formula 


Xll 


CONTENTS. 


PAGE 

Coloured  Plates  with  Descriptive  Letterpress          -          -  695 

PLATE 

I.  Varieties  in  Form  of  the  Normal  Larynx  as  seen  in  the  Mirror  -  697 

IL  Acute,  Subacute,  and  Chronic  Pharyngitis       -          -          -  699 

III.  Syphihtic  Disease  of  the  Pharynx         -          -          .          .  yoi 

IV.  Diseases  of  the  Uvula  and  Tonsils       -          -          .          .  ^03 
V.  Acute  Tonsillitis — Pharyngitis  Sicca — The  Rhiniscopic  Image 

and  Diseases  of  the  Posterior  Nares — Diphtheria       -           -  705 
VI.  Simple  Inflammations  of  the  Larynx — Traumatic  Laryngitis — 

Diphtheria     -------  yoy 

VII.  Syphilitic  Laryngitis     -          -          -          -          -          -  709 

VIII.  Anaemia  of  the  Larynx — Tubercular  Laryngitis — Disease  of  the 

LaryngeaP  Cartilages  -          -          -          -          -          -  711 

IX.  Benign  Neoplasms  in  the  Larynx — Malignant  Disease  of  the 

Pharyngo-Larynx  and  Larynx           -          -          -          -  713 

X.  Neuroses  of  the  Larynx           -          -          -          -          -  715 

XI.  Tuberculous  Laryngitis            -          -          -          -          -  717 

XII.  Tuberculous  Laryngitis,  etc.     -          -          -          -          -  7^9 

XIII.  Syphilitic  and  Scrofulous  Ulceration  of  the  Pharynx — Pharyn- 

gitis Sicca — Epithelioma  of  the  Palate  and  Tonsil      -           -  721 

XIV.  Diphtheria — Lupus — Sarcoma — Epithelioma,  etc.        -          -  723 
XV.  The  Lymphatic  Vessels  of  the  Base  of  the  Tongue,  Tonsils, 

Larynx,  and  Pharynx — Photo-lithograph          6'^//<?j)         -  724 


General  Index 


725 


LIST  OF  ENGRAVINGS. 


[The  figures  of  instruments  and  those  descriptive  of  the  anatomy  are  printed  from 
drawings  on  wood.  Those  representing  diseased  conditions  are,  with  a  few  exceptions, 
facsimile  reproductions  of  the  author's  pen-and-ink  sketches,  by  the  process  known  as 


Direct  Photo-engraving.] 

FIG.  PAGE 

I.  Side  View  of  Larynx  -          -          -          -          -  *  7 

II.  Front  View  of  Larynx          -          -          -          -  -  8 

III.  Side  View  of  Larynx,  showing  the  Interior    -          -  -  9 

IV.  Side  View  of  Larynx,  showing  the  Left  Interior  Muscles  -  lo 
V.  Side  View  of  Larynx,  showing  the  Left  Ventricle      -  -  1 1 

VI.  View  of  Larynx  Opened  from  Behind          -          -  -  12 

VII.  The  Larynx  in  Gentle  Breathing       -          -          -  -  16 

VIII.  The  Larynx  in  Tone  Production       -          -          -  -  16 

IX.  The  Larynx  in  Deep  Breathing        -          -          -  -  16 

X.  The  Muscles  of  the  Larynx  seen  from  Behmd         -  -  18 
XI.  Side  View  of  the  Larynx,  showing  the  Right  Crico-thyroid 

Muscle     -          -          -          -          -          -  -  21 

XII.  View  of  a  Horizontal  Section  of  Larynx  from  Above  -  -  22 

XIII.  A.  Glottis  in  Repose.    B.  In  Deep  Inspiration.   C.  In  Tone 

Production          -          -          -          -          -  -  24 

XIV.  The  Muscles  of  the  Soft  Palate  and  Pharynx  -          -  -  26 
XV.  Sectional  View  of  the  Pharynx         -          -          -  -  29 

XVI.  Side  View  of  Muscles  of  Pharynx     -          -          -  -  30 

XVII.  Anterior  Section  of  the  Nostrils  {afier  Lusc/ika)        -  -  33 

XVIII.  Vertical  Section  of  Head,  showing  Cavity  of  Nose    -  -  34 

XIX.  Standard  Gas  Lamp  -          -          -          -          -  -  40 

XXU.  The  Zemtox-Browne  Limelight  App3irsLius     -          -  -  41 

XXIII.  Laryngeal  Reflector  -          -          -          -          -  -  45 

XXIV.  The  Laryngeal  Mirror          -          -          -          -  -  46 
XXV.  Diagram  illustrating  the  Principle  of  the  Laryngoscope  -  47 

XXVI.  Diagram   of  Laryngeal    Mirror,  illustrating  Reversion  of 

Reflected  Image  -                    -                    -  -  47 


XIV 


LIST  OF  ENGRA  VINGS. 


FIG.  PAGE 

XXVII.  Position  of  Observer's  Hands  in  making  a  Laryngoscopic 

Examination     -           -           -           -           -           -  49 

XXVIII.  Hill's  Folding  Tongue  Depressor  and  Retractor   -          -  56 

XXIX.  Wingrave's  Automatic  Mouth-Prop          -          -          -  57 

XXX.  Tne  Soft  Palate    -          -          -          -          -          -  59 

XXXI.  Sectional  View  showing  Position  of  Mirror  for  giving 

Minimum  of  View  of  Larynx    -          -          -          -  62 

XXXII.  The  same  for  giving  a  Full  View  -          -          -          -  63 

XXXIII.  Side  View  of  Larynx,  showing  Right  Ventricle  Open       -  64 

XXXIV.  Laryngeal  Image — Lower  Thick  Register  -          -          -  68 
XXXV.  Laryngeal  Image — Upper  Thick  Register  -          -  -69 

XXXVI.  Laryngeal  Image — Lower  Thin  Register  -  -  -70 

XXXVII.  Laryngeal  Image — Upper  Thin  Register  -  -  -  70 

XXXVIII.  Laryngeal  Image — Small  Register           -  -  -  7° 

XXXIX.  Soft  Palate  in  Tone  Production  (F)        -  -  -  71 

XL.  Soft  Palate  in  Tone  Production  (A)        -  -  -71 

XLI.  Soft  Palate  in  Tone  Production  (C  pure)  -  -  -  71 

XLII.  Soft  Palate  in  Tone  Production  (C  nasal)-  -  -  71 

XLIII.  Auto-Laryngoscope  of  Foulis       -          -  -  -  73 

XLIV.  Stein's  Photo-Laryngoscope         -          -  -  -  75 

XLV.  Stein's  Photo-Laryngoscope         -          -  ■  ■  75 

XLVI.  Duplay's  Nasal  Speculum  -          -          -  -  -  77 

XLVII.  Fraenkel's  Nasal  Speculum          -          -  -  -  77 

XLVIII.  Thudichum's  Nasal  Speculum      -          -  -  -  77 

XLIX.  Elsberg's  Nasal  Speculum,  with  Author's  Rack  Movement  78 

L.  The  Len7iox  Browne  Nasal  Speculum      -  -  -78 
LI.  Curve  of  Shank  of  Mirror,  and  Position  of  Hand  necessary 

for  Rhinoscopy  -          -          -          -  -  -  81 

LI  I.  Fraenkel's  Rhinoscopic  Mirror     -          -  -  -  81 

LIII.  Section  showing  Position  of  Mirror  and  Patient's  Head 

for  obtaining  a  Rhinoscopic  Image      -  -  -  82 

LIV.  The  Posterior  Rhinoscopic  Image           -  -  -  ^5 
LV.  View  of  the  Posterior  Nares,  the  Pharynx  being  laid  Open 

from  Behind  {after  Luschkd)     -          -  -  -  86 

LVI.  Oudines  of  (A)  Fauces,  (B)  Posterior  Nares,  (C)  Section 

of  Nares,  and  (D)  Larynx        -          -  -  -  90 

LVII.  Sectional  View  of  Corby n's  Double-Valve  Inhaler-  -  105 

LVJII.  The  Murch  Hospital  Inhaler       -          -  -  -  ic6 

LIX.  Lee's  Steam  Draught  Inhaler       -          -  -  -  107 

LX.  Pharyngeal  Spray  Producer         -          -  -  -  iii 

LXI.  Double  Handball  Throat  Spray  Producer  -  -  iii 

LXII.  An  Improved  Siegle's  Atomizer    -          -  -  -  112 

LXIII.  Laryngeal  Syringe   ~       -          -          -  -  -  112 

LXIV.  Pneumatic  Pump  -          -          -          -  -  -  113 


LIST  OF  ENGRA  VINGS. 


XV 


FIG.  PAGE 

LXV.  Hamilton's  Fumigator  and  Atomizer    -          -  - 

LXVI.  Leiter's  Pliable  Metal  Temperature  Regulator  -  -117 

LXVII.  The  Anterior  Syphon  Nasal  Douche    -          -  -120 

LXVIII.  Harrison  Allen's  Apparatus  for  Anterior  Nasal  Douche  120 
LXIX.X 
LXX 

*  l  Author's  Posterior  Nasal  Syringes       -          -  -  121 
JLXXl.  I 

LxxnJ 

LXXni.  The  Z#^r/^  Coarse  Spray        -          -          -  -  122 

LXXIV.  ThG  Zennox  Brozvne  NsLSsd  HsLud  Syringe        -  -  123 

LXXV.  Laryngeal  Sponge-Holder        -          -          -  -  125 

LXXVI.  Ditto  with  Catch  to  secure  the  Sponge           -  -  125 

LXXVII.  The  same  with  Catch  closed    -          -          -  -  125 

LXXVni.  Smyly's  Cotton-wool  Brush      -          -          -  -  125 

LXXIX.  Terminals  of  Cotton-wool  Brushes       -          -  -  126 

LXXX.  Author's  Laryngeal  Brush        -          -          -  -  126 

LXXXL  Rauchfuss's  Laryngeal  Insufflator        -          -  -  127 

LXXXH.  Labiersky's  Laryngeal  Insufflator         -          -  128 

LXXXIIL  Simple  Caustic  Holder           -          -          -  -  128 

LXXXIV.  Jarvis's  Laryngeal  Porte-Caustique       -          -  -  129 

LXXXV.  Laryngeal  Lancet         -          -          -          -  -  130 

LXXXVL  Gibb's  Laryngeal  Snare           -                    -  -  130 

LXXXVII.  Carmalt  Jones's  Laryngeal  and  Nasal  Snare     -  -  131 

LXXXVIII.  Voltolini's  Laryngeal  Sponge  Probang  -          -  132 

LXXXIX.  Varieties  of  Fauvel's  Ivaryngeal  Growth  Forceps  -  132 

XC.  Laryngeal  Electrode     -          -          -          -  -  134 

XCI.  Author's  Galvano-Caustic  Battery  (Mayer)       -  -  i35 

XCIII.  Author's  Galvano-Caustic  Points  and  Loops  (Mayer)   -  137 
XCIV.  E.  P.  S.  Galvano-Cautery  Accumulator  with  Rheostat 

(Coxeter)      -          -          -          -          -  -  138 

XCV.  Instruments  for  Securing  Nasal  Polypi  -          -  -  i39 

XCVI.  Wilde's  Snare  for  Nasal  Polypus          -          -  -  140 

XCVII.  Hamilton's  Instrument  for  the  same  Purpose  -  -  140 

XCVIII.  Long  Forceps  for  Nasal  Polypus         -          -  -  140 

XCIX.  Lund's  Ring  Forceps  for  the  same  Purpose     -  -  140 

CI.  Author's  Improved  CEsophageal  Ramoneur     -  -  141 

CII.  Acute  Pharyngitis,  with  Exudation       -          -  -  182 

cm.  Chronic  Pharyngitis  Lateralis  Hypertrophica    -  -194 

CIV.  Secondary  Syphilis  in  the  Fauces         -          -  -  201 

CV,  Multiple  Tertiary  Ulcerations  of  Soft  Palate,  etc.  -  205 

CVI.  Central  Tertiary  Perforation  of  Hard  and  Soft  Palate  -  206 
CVII.  and^CVIII.  Syphilitic  Adhesion  of  Uvula  to  Faucial 

Pillars          ------  208 

CIX.  Hereditary  Syphilitic  Ulceration  of  Pharynx     -  -  210 


xvi 


LIST  OF  ENGRA  VINGS. 


FIG.  PAGE 

ex.  Tuberculous  Ulceration  of  Velum  and  Fauces  -          -  217 

CXI.  Larynx  of  the  same  Patient     -          -          .          -  217 

CXII.  Varix  of  Base  of  the  Tongue    -          -          .          .  223 

CXIII.  Uvula  P'orceps  and  Scissors  in  Position  fur  Operating  -  235 

CXIV.  Congenital  Double  Uvula,  with  Relaxation      -          -  237 

CXV.  Magnified  Section  of  a  (slightly)  Hypertrophied  Tonsil  240 
CXVI.  Tonsil  Guillotine,  in  Position  for  Operating  on  the  Left 

Tonsil  256 

CXVII.  Wire-Loop  Ecraseur  for  Enlarged  Tonsils        -          -  257 

CXVIII.  Calcareous  Formation  extruded  from  the  Tonsil         -  261 

CXIX.  Lympho-Sarcoma  of  the  Tonsil           -          -          -  263 

CXX.  Primary  Epithelioma  of  the  Tonsil      -          -          -  265 

CXXI.  Epithelioma  of  Anterior  Pillar  of  Fauces         -          -  266 

CXXIL  Section  of  Vocal  Cord  and  Ventricle,  Magnified         -  271 

CXXIIL  Paralysis  of  Thyro-arytenoidei  in  Laryngitis     -          -  285 

CXXIV.  Paralysis  of  Arytenoideus  in  Laryngitis           -          -  285 

CXXV.  Imperfect  Approximation  from  Swelling  in  Laryngitis  -  285 

CXXVI.  Primary  Perichondritis  of  Larynx        -          -          -  312 
CXXVIL^i 

CXXVIII.  Primary  Perichondritis  of  Larynx.     Various  Views 

CXXIX.      under  different  Stages  of  Treatment  -          -          -  314 
CXXX.. 

CXXXI.  Syphilitic  Perichondritis          -          -          -          -  315 

CXXXII.  Laryngeal  Chondro-Sarcoma  and  Perichondritis          -  316 

CXXXIII.  Post-mortem  Appearance  of  Throat  with  Diphtheria    -  346 

CXXXIIIa.  Intubation  Instruments.  (Misprinted  CXXV^?.)  -  372 
CXXXIII^.  Diagram  illustrating  Curve  for  introducing  Intubator. 

(Misprinted  CXXV^.)          -          -          -          -  374 

CXXXI V.  Tertiary  Syphilitic  Ulceration  of  Larynx          -          -  39^ 

CXXXV.  The  same  after  five  weeks'  Treatment  -          -          -  390 

CXXXVL  Whistler's  Cutting  Dilator        -          -          -          -  392 

CXXXVII.  Cicatricial  Stenosis  of  Larynx  -          -          -          -  393 

CXXXVIII.  The  same  after  Treatment       -          -          -          -  393 

CXXXIX.  Author's  Hollow  Laryngeal  Dilator  with  Cutting  Blade  393 

CXL.  Tuberculous  Inflammation  of  Larynx  -          -          -  410 

CXLI.  Tuberculous  Infiltration  of  Larynx       -          -          -  412 

CXLII.  Carious  Ulceration,  etc.,  of  Tuberculous  Laryngitis     -  413 

CXLIII.  Tuberculous  Ulceration  of  Pharynx,  etc.         -          -  423 

CXLIV.  Laryngoscopic  Appearance  of  the  same  Case   -          -  423 

CXLV.  Lupus  of  the  Nose  and  Upper  Gums   -          -          -  429 

CXLVI.  Condition  of  the  Pharynx  in  the  same  Case     -          -  429 

CXLVII.  Condition  of  the  Larynx  in  the  same  Case       -          -  429 

CXLVIIL  Lupus  of  the  Soft  Palate         .          -          .          ,  434 

CXLIX.  Palatal  Appearance  of  Lupus              -          -          •  436 


LIST  OF  ENGRA  VINGS. 


xvii 


FIG.  PAGF. 

CL.  Laryngoscopic  Appearance  of  the  same         -          -  436 

CLL  Early  Lupous  Infiltration  of  Uvula     -          -          -  436 

CLII.  Early  Lupus  of  Uvula  and  Velum       -          -          -  436 

CLIIL  Early  Lupous  Ulceration  of  Anterior  Faucial  Pillar     -  437 

CLIV.  Lupus  of  Soft  Palate  and  Uvula         -  .        -          -  437 
CLV.  Lupus  of  the  Larynx  -          -          -          -  -437 

CLVI.  Thickening  of  Epiglottis  in  Lupus      -          -          -  437 
CLVII.  Inflammatory  Thickening  and  Modulation  of  Epiglottis 

in  Lupus     ------  438 

CLVIII.  Laryngeal  Appearance  in  (so-called)  Lupoid  Inflam- 
mation       -          -          -          -          -          -  441 

CLVIII*.  The  same  eleven  months  later           -          -          -  44^ 
CLIX.  Faucial  Appearance  in  the  same  Case  -          -  -441 

CLX.  Laryngeal  Appearance,  Syphilis  simulating  Lupus      -  442 

CLXa.  Leprosy  of  Larynx     -          -          -          -          -  445 

CLXI.  Cystic  Growth  on  Epiglottis,  Polypi  on  Right  Cord    -  449 

CLXII.  Multiple  Papillomata  of  Larynx         -          -          -  45° 
CLXIII.  Mucous  Polypus  on  Vocal  Cord  (Respiration  and 

Phonation)  ------  450 

CLXIV.  Papillomata  on  Vocal  Cords    -          -          .          .  450 

CLXV.  Cystic  Growth  on  Left  Vocal  Cord     -          -          -  451 

CLXVI.  Papilloma  at  Anterior  Insertion         -          -          -  45i 

CLXVII.  Papillomata  on  Epiglottis  and  Left  Vocal  Cord         -  453 

CLXVIII.  Small  Fibroma  on  Left  Vocal  Cord    -          -          -  45^ 

CLXIX.  Multiple  Papillomata  of  Larynx         -          -          -  457 

CLXX.  Papilloma  at  Anterior  Insertion  of  Cords       -          -  457 
CLXXI.  Papillary  Growths  on  Right  Vocal  Cord  (Respiration 

and  Phonation)       -          -          -          -          -  461 

CLXXIL  Papilloma  on  Right  Vocal  Cord        -          -  .462 
CLXXIII.  Symmetrical  Papillary  Growths  on  Vocal  Cords         -  462 
CLXXIV.  Multiple  Papillomata  of  Larynx,  Three  Views  (Respi- 
ration and  Phonation)         -          -          -          -  462 

CLXXV.  Multiple  Papillomata  of  Larynx,  July,  1885    -          -  463 

CLXXVI.  The  same  Case,  January,  1886          -          -          -  463 

CLXXVII.    „       „       „     October,  1886          -          -          -  463 

CLXXVIII.    „       „       „     February,  1887         -          -          -  463 

CLXXIX.  Growth  on  Right  Vocal  Cord  (Two  Views)     -          -  464 

CLXXX.  Guarded  Wheel  Ecraseur        -          -          -          .  464 
CLXXXI.  Lymphatics  of  the  Larynx  and  Trachea  in  the  Adult 

(a//er  Sappey)         -           -           -           -           -  470 

CLXXXII.  Laryngo-Pharyngeal  Epithelioma        -          -          -  475 

CLXXXIII.  Pharyngo-Laryngeal  Sarcoma  -          -          -          -  479 

CLXXXIV.  Epithelioma  of  Posterior  Wall  of  Larynx        -          -  482 

CLXXXV.  Lympho-Sarcoma  of  Tonsil,  Pharynx,  and  Larynx      -  484 


XVlll 


LIST  OF  ENGRA  VINGS. 


FIG.  I'AGE 

CLXXXVI.  Fauces  fourteen  days  after  Operation  -           -          -  484 

CLXXXVII.  Larynx  fourteen  days  after  Operation            -          -  484 

CLXXXVIIL  Sarcoma  of  Larynx,  October  14,  1876           -          -  486 

CLXXXIX.  Sarcoma  of  Larynx,  December  6,  1877          -          -  486 

CXC.  Intra- Laryngeal  Epithelioma  before  Operation          -  495 
CXCL  Intra- Laryngeal    Epithelioma    sixteen   weeks  after 

Operation  ------  496 

CXCII.  Intra-Laryngeal   Epithelioma   (Internal    Aspect  of 
Removed  Portion)-  .  .  .  . 

CXCIII.  Intra-Laryngeal  Epithelioma  (Microscopic  Appear- 
ance of  Surface)     -          -          -          -          -  497 

CXCIV.  Intra-Laryngeal  Epithelioma  (Microscopic  Appear- 
ance of  Deeper  Section)    -          -          -          -  497 

CXCV.  Nasal  Secretion  from  Hay-fever         -          -          -  566 

CXCV"^.  Chromic  Acid  Applicator      -          -          -          -  577 

CXCVI.  Coronal  Section  showing  Deviation  of  Septum          -  593 

CXCVIL  Ditto-          -          -          -          -          -          -  594 

CXCVIII.  Dundas  Grant's  Splint  for  Deviated  Septum   -  599 

CXCIX.  Hewetson's  Nasal  Dilator  with  Author's  Modifications  600 

CC.  Hill's  Nasal  Dilator  and  Septum  Straightener           -  600 

CCL  to  CCXX.  Diagrams  representing  Anterior  Rhino-^l  601 

scopic  Appearance   of  Septal  Deflections  and  j  to 

Spurs        -          -          -          -          -         j  607 

CCXXL  Mucous  Popypus  of  Nose      -          -          -          -  614 

CCXXII.  Microscopic  Section  of  Adenoid  Hypertrophy          -  639 
CCXXIII.  Author's  Finger-guard,  with  Extension  Curette,  Spoon, 

etc.           ------  644 

CCXXIV.  Hovell's  Soft  Rubber  Finger-guard    -          -          -  644 
CCXXV.  Schutz's    Antero-Posterior    Forceps    for  Adenoid 

Growths     -----          -  644 

CCXXvJ'  I  N^^o-P^^'^^y^g^'^^  Curettes      -          .          -          .  646 

CCXXVI.  Gardiner  Brown's  Tuning-Fork         -          -          -  655 

CCXXVII.  Membrana  Tympani  (a/fer  PolHzer)  -          -          -  658 
CCXXVIII.  Diagrams  of  Membrane  for  Case-taking         -  663  and  667 

CCXXIX.  Author's  Politze?'  Bag  for  Patient's  use          -          -  673 

CCXXX.  Keene's  Form  of  i^.'V/Vsf;' Bag           -          -          -  673 

CCXXXI.  Ward  Cousins' Instrument  for  Tinnitus          -          -  674 


PREFACE  TO  THE  FOURTH  EDITION. 


This  book  has  been  out  of  print  for  two  years,  and,  as  on  each 
former  occasion  of  a  new  edition,  I  have  to  express  my  regret  for 
undue  delay  in  reproducing  it. 

Once  more,  however,  I  can  plead  that  this  delay  is  not  alto- 
gether without  advantage  to  the  reader.  The  science  of  laryn- 
gology progresses  so  rapidly  that  even  a  short  interval  enforces 
many  changes  in  our  conceptions.  Views  that  a  little  while  ago 
were  held  provisionally  have  been  disproved  by  experience,  and 
others  that  had  to  be  sustained  by  lengthy  arguments  may  now 
be  shortly  stated  as  facts.  I  have  endeavoured  to  profit  by  the 
advance  of  knowledge,  and  I  trust  that  this  edition,  though  not 
much  larger  than  the  last,  will  be  found  to  satisfactorily  reflect 
all  recent  information  of  value. 

A  portion  of  the  space  gained  by  abbreviation  has  been  devoted 
to  further  details  of  the  influence  of  micro-organisms  in  producing 
throat  diseases  ;  and  in  this  connection  it  may  be  permissible  to 
refer  to  the  corroboration  of  the  views  I  have  always  held  as  to 
the  non-identity  of  croup  and  diphtheria  which  recent  bacterio- 
logical investigations  appear  to  afford  {vide  pp.  162,  354,  378). 

Other  experiments  confirm  the  contention  advanced  on  purely 
clinical  grounds  in  my  second  edition  (1887),  under  the  heading 
of  a  ptomaine  theory  of  diphtheria,  that,  in  addition  to  a  specific 
organism  of  this  disease,  we  have  to  deal  with  resultant  specific 


XX  PREFACE  TO  THE  FOURTH  EDITION. 

poisons,  in  the  shape  of  albumins  and  ptomaines,  which  pass  into 
and  contaminate  the  blood. 

But  the  main  feature  of  this  new  edition  has  been  the  expansion 
of  that  portion  of  the  work  which  deals  with  diseases  of  the  nose, 
for,  to  quote  again  from  the  preface  of  the  last  issue  :  '  Especial 
note  has  been  taken  of  the  circumstance  that  laryngology,  which 
formerly  depended  almost  entirely  upon  the  somewhat  limited 
revelations  of  the  laryngeal  mirror,  is,  in  these  later  times,  assum- 
ing a  new  aspect,  and  opinion  is  each  day  becoming  more  indis- 
putable that  in  the  condition  of  the  nasal  fossae,  which  constitute 
the  first  avenues  of  the  natural  breathway,  is  to  be  found  the  key 
to  a  right  understanding  and  successful  treatment  of  the  majority 
of  faucial,  pharyngeal,  and  laryngeal  diseases.' 

This  growing  importance  of  rhinology  has  been  promptly 
recognised  by  laryngologists,  and  for  the  most  part  by  aurists. 
It  is,  moreover,  securing  the  attention  it  deserves  from  our 
younger  surgeons,  and  it  is  therefore  to  be  greatly  regretted  that 
a  general  surgeon,  who  may  be  said  to  have  won  his  spurs  by  a 
prize  essay  on  diseases  of  a  region  involving  the  accessory  cavities 
of  the  nose,  should  have  permitted  himself,  and  have  been  per- 
mitted, to  recently  deliver  in  one  of  our  royal  colleges  a  lecture 
which  had  for  the  avowed  purpose  the  pouring  of  ridicule  on  the 
progress  ot  nasal  surgery  at  the  hands  of  specialists. 

The  result  of  the  discussion  of  this  address  is  just  what  might 
have  been  expected.  Derision  has  recoiled  on  the  derider ;  the 
specialist  has  been  all  the  more  stimulated  to  justify  his  position 
by  good  work ;  and  the  younger  general  surgeon  has  been  led 
to  take  all  the  greater  interest  in  the  exploration  of  a  territor}- 
which,  until  illumined  by  the  search-light  of  the  expert,  had 
been  almost  a  dark  continent. 

15,  Mansfield  Street, 

Portland  Place,  W. 
/ji/?e,  1893. 


DISEASES 

OF  THE 

THROAT    AND  NOSE. 


INTRODUCTORY. 

A  FEW  words  with  regard  to  the  aims  and  plan  of  this  work  may 
be  useful  to  the  reader. 

Necessity  no  longer  exists  for  enforcing  the  value  of  the  laryngo- 
scope. By  its  means,  not  only  are  many  special  local  maladies, 
otherwise  invisible  during  life,  brought  directly  under  the  eye  of 
the  observer,  but  in  many  serious  general  diseases,  such  as 
phthisis,  cancer,  and  syphilis,  as  well  as  in  cases  of  aneurismal 
or  glandular  tumours,  the  local  condition  of  the  larynx  thus 
revealed  will  at  a  very  early  period  enable  us  to  form  a  diagnosis 
and  prognosis,  which  without  such  knowledge  would  be  often 
erroneous,  or  at  least  doubtful. 

^Ziemssen*  has  proposed,  and  ^Elsberg  has  also  insisted,  that 
courses  on  laryngoscopy  and  laryngological  technics,  as  well  as 
other  methods  of  diagnostic  and  therapeutical  procedures,  should 
precede  attendance  on  general  clinical  instruction,  the  argument 
being  based  on  correct  appreciation  of  the  fact  that  unless  the 
student  is  already  in  possession  of  the  technical  ability  required, 
the  mere  looking  on  the  performances,  or  listening  to  the  words, 
of  the  best  clinical  teacher  is  comparatively  valueless  for  his  own 
doings  in  practice.  Until  some  change  in  this  direction  is  effected, 
practical  skill  in  technical  specialties,  such  as  laryngology,  ophthal- 
mology, and  otology  must  be  confined  to  the  minority  of  students 
conscientiously  desirous  to  equip  themselves  at  all  points  for  their 

^  The  small  numerals  attached  to  the  names  of  authorities  refer  to  the  Bibliographical 
Ijjist  at  the  end  of  each  chapter, 

I 


2 


DISEASES  OF  THE  THROAT  AND  NOSE. 


life-long  battle  with  disease,  and  to  the  still  smaller  number  of 
the  many,  who,  made  conscious  of  their  deficiencies  only  after 
their  entrance  into  practice,  have  the  opportunity,  by  post- 
graduate courses,  of  acquiring  that  information  and  facility  un- 
attained — possibly  unattainable — in  their  days  of  studentship. 

In  the  hope  of  supplying  this  want — so  far,  at  least,  as  written 
pages  can  substitute  personal  instruction — this  book  has  been 
written. 

Clinical  study,  as  the  name  implies,  can  only  be  efficiently 
pursued  in  the  presence  of  the  patient  ;  but  I  have  endeavoured  to 
frame  a  work  which,  in  its  bearings,  is  intended  to  be  essentially 
clinical.  It  is,  however,  hardly  necessary  to  give  the  warning  that 
rules  for  general  instruction  cannot  always  be  applied  without 
modification  to  individual  cases. 

Attention  is  mainly  directed  to  the  diagnosis  and  treatment  of 
those  diseases  of  the  throat  which  have  been  brought  more  pro- 
minently into  view  since  the  introduction  of  the  laryngoscope. 

But  the  strong  reflected  light  necessary  for  laryngoscopy  has 
aided  in  more  accurate  observation  of  diseases  of  the  fauces  and 
pharynx ;  and  the  rhinoscope,  a  corollary  of  the  laryngeal  mirror, 
has  been  of  similar  service  in  reference  to  disorders  of  the  naso- 
pharyngeal and  nasal  passages.  Equal  consideration  is  therefore 
given  to  the  various  morbid  conditions  of  these  regions. 

Those  affections  which  may  be  considered  pecuHar  to  the  throat 
and  nose  are  fully  discussed,  both  with  reference  to  their  local 
symptoms  and  their  effect  on  the  general  health.  In  the  case, 
however,  of  those  diseases,  such  as  diphtheria,  syphiHs,  and 
phthisis — which,  although  manifesting  grave  symptoms  in  the 
throat  and  requiring  special  local  treatment,  are  in  point  of  fact 
primarily  the  result  of  a  general  poison — attention  is  given  prin- 
cipally to  the  diagnosis  and  treatment  of  the  local  malady. 

The  chapters  on  deafness  in  relation  to  affections  of  the  throat 
and  nose,  introduced  in  the  second  edition,  are  retained ;  and 
albeit  no  further  amplified  in  this  later  one,  I  venture  to  deprecate 
the  criticism  that  because  of  their  brevity  they  might  be  omitted ; 
for  although  perhaps  they  comprise  not  much  more  than  an 
enumeration  of  the  aural  maladies  dependent  on  morbid  conditions 
of  the  throat  and  nose,  with  but  general  indications  for  treatment, 
the  whole  book  emphasizes  the  close  association  of  these  regions, 
and  consequently  the  importance  of  a  thorough  aural  examination, 
in  all  cases  which  may  be  presented  to  the  specialist. 

With  the  intention  of  avoiding  unnecessary  repetition,  the 
earlier  chapters  are  written  with  such  method  and  detail  as  to 


INTRODUCTORY. 


make  them  a  key  to  the  rest  of  the  work.  In  order,  then,  that 
the  later  portions  may  be  well  understood,  it  is  essential  that  the 
preliminary  chapters  be  carefully  studied,  and  their  lessons 
thoroughly  mastered  with  the  aid  of  frequent  examinations  of  the 
healthy  throat  and  larynx ;  dihgence  and  perseverance  being  as 
necessary  for  this  purpose  as  they  are  for  a  perfect  knowledge  of 
healthy  chest-sounds  as  revealed  by  the  stethoscope,  or  of  the 
normal  fundus  of  the  eye  by  the  ophthalmoscope.  The  student 
may  further  perfect  himself  by  adopting  one  of  the  methods  of 
auto-laryngoscopy. 

In  this  edition  the  section  on  Regional  Anatomy  and  Physio- 
logy, which  is  much  fuller  than  in  the  former,  is  placed  first. 
This  position  does  not  interfere  with  the  continuity  of  the  work, 
and  the  contents  may  be  perused  or  *  skipped,'  according  to  the 
inclination  or  state  of  knowledge  of  the  reader. 

The  chapters  on  Semeiology  and  General  Therapeutics  are  also 
given  very  fully ;  and  unless  these  be  attentively  considered,  the 
importance  of  the  references  to  differential  symptomatology  and 
treatment  of  the  various  diseases,  later  considered  under  their 
separate  headings  cannot  be  appreciated. 

From  a  desire  not  to  unnecessarily  increase  the  bulk  of  the 
work,  or  to  destroy  its  practical  character,  I  omitted  in  the 
first  edition  '  questions  of  purely  pathological  interest.'  I  admit 
the  justice  of  the  criticism  from  more  than  one  source,  that 
my  reticence  in  this  respect  was  carried  to  excess,  and  that  the 
book  would  have  been  made  more  valuable,  and  no  less  practical, 
by  the  insertion  of  more  complete  pathological  data.  This  want 
I  have  now  endeavoured  to  supply ;  first,  by  a  new  chapter  on 
the  General  Etiology  and  Pathology  of  the  subject,  and  also  by 
direct  consideration  of  the  morbid  anatomy,  as  observed  during 
life,  of  each  disease  when  separately  treated.  With  a  few  excep- 
tions— those  of  laryngeal  phthisis,  cancer,  and  diphtheria — I  have 
felt  constrained,  for  the  reasons  originally  given  in  the  Preface  to 
the  first  edition,  to  adhere  to  my  decision  not  to  include  illustra- 
tions or  descriptions  of  post-mortem  appearances. 

In  the  separate  discussion  of  each  form  of  disease  the  arrange- 
ment of  signs,  symptoms,  and  methods  of  treatment  adopted  in 
these  general  chapters  is  as  far  as  possible  followed.  I  am  aware 
that  such  a  plan  is  open  to  certain  objections,  and  may  some- 
times cramp  the  flow  of  description  ;  but  the  advantages  for 
reference  and  comparison  of  a  uniform  method  to  the  busy  prac- 
titioner have  appeared  to  me  to  offer  ample  compensation. 

Histories  of  cases  in  detail  were  for  the  most  part  excluded 

I — 2 


4 


DISEASES  OF  THE  THROAT  AND  NOSE 


in  the  earlier  edition.  This  rule  is  now  somewhat  modified,  and 
without  intention  to  make  the  volume  a  mere  transcript  of  my 
note-book,  short  accounts  of  cases  are  given  wherever  their  narra- 
tion is  thought  likely  to  elucidate  points  of  pathology,  diagnosis, 
or  practice.  In  addition,  all  the  drawings  of  diseased  appearances, 
whether  in  the  text  or  in  the  coloured  plates,  are  accompanied  by 
explanatory  notes  bearing  on  the  nature  of  the  cases  illustrated. 

Pictorial  illustrations  of  disease  as  seen  with  the  laryngoscope 
and  rhinoscope  are  believed  to  be  essential  to  any  work  intended 
as  a  practical  guide.  The  illustrations  of  the  present  volume  have 
all  been  taken  from  nature.  The  engravings  represent  my  own 
drawings  on  the  wood,  or  are  fac-simile  reproductions.  The 
lithographs  also  were  placed  on  the  stone  by  myself.  In  the 
first  coloured  plate  of  the  normal  laryngeal  image  every  variety 
and  form  of  healthy  larynx  is  figured  ;  but  afterv/ards,  in  plates 
illustrative  of  disease,  only  those  points  which  are  departures 
from  the  normal  are  indicated,  and  a  type  is  taken  all  through  of 
the  most  usual  forms  of  larynx — that  seen  in  Figs,  i  and  2  of 
Plate  I.  Intended  to  represent  types  of  disease,  the  drawings 
have  in  a  few  instances  been  somewhat  conventionalized — that  is 
to  say,  accidental  differences  of  portraiture  have,  for  the  sake  of 
simplicity,  been  omitted.  Plates  I.  and  X.,  which  in  the  first 
edition  were  rendered  as  photographs  in  autot3^pe  of  my  original 
drawings,  are  now  represented  by  lithographs  in  monochrome. 
Four  other  coloured  plates  further  elucidating  the  lar3'ngoscopic 
and  morbid  appearances  of  Tuberculosis,  Syphilis,  Lupus,  Cancer, 
and  Diphtheria  have  been  added. 

The  lithographic  illustrations  are  arranged  with  especial  regard 
to  more  convenient  reference  than  is  usually  possible.  Each  plate 
can  be  opened  out  so  as  to  lie  beside  the  book  during  perusal  of 
the  text  descriptive  of  the  disease  pictorially  illustrated. 

Wood  engravings,  most  of  which  are  original,  have  been  inserted 
where  necessary.  Their  number  in  this  edition  is  more  than  treble 
that  in  the  former ;  and  this  increase  is  largely  due  to  the  fact 
that  I  have  been  able  to  include  a  very  complete  series  of  original 
illustrations  of  the  anatomy  of  the  larynx  from  Voice,  Song,  and 
Speech,  For  permission  to  do  this  I  am  indebted  to  m}^  esteemed 
friend  and  co-author  of  that  work,  Mr.  Emil  Behnke,  and  also  to 
the  publishers,  Messrs.  Sampson  Low,  Marston,  and  Co.  I  have 
likewise  added  several  new  figures  illustrating  the  anatomy  of  the 
pharynx,  nares,  and  soft  palate,  numerous  original  drawings  of 
laryngoscopic  portraits  of  disease,  and  some  interesting  views  of 
the  larynx  and  soft  palate  in  tone-production — these  last  also  from 
Voice,  Spngi  and  Speech 


INTRODUCTORY. 


As  to  the  instruments,  except  occasionally  for  pur 
parison,  only  those  found  of  value  in  ray  own  practice  a 
They  are  generally  drawn  to  scale,  so  as  to  be  available  as 
ing  drawings.  The  majority  of  the  instruments  illustrated  and 
described  have  been  made  for  me  according  to  my  patterns 
by  Messrs.  Krohne  and  Sesemann,  of  Duke  Street,  Manchester 
Square ;  but  I  am  also  much  indebted  to  Messrs.  Coxeter  and  to 
Messrs.  Mayer  and  Meltzer  for  carrying  out  and  perfecting  several 
of  my  crude  suggestions  as  to  new  instruments  and  improvements. 
Without  the  mechanical  and  practical  skill  of  such  firms,  the 
so-called  inventions  of  many  of  us  would  prove  but  of  slight  utility 
when  tested  in  the  consulting-room  or  operating  theatre. 

As  mentioned  in  the  preface,  care  has  been  exercised  to  give 
the  names  of  all  to  whom  credit  is  accorded  for  originality  as  well 
as  of  those  from  whom  I  may  differ  on  points  of  theory  and 
practice,  and  any  omission  in  either  of  these  directions  is  acci- 
dental. With  a  view,  however,  of  ensuring  greater  comfort  of 
perusal,  the  luxury  of  foot-notes  or  intercalated  references  is 
.altogether  dispensed  with,  and  their  space  supplied  by  a  biblio- 
graphical list  of  references  at  the  end  of  each  chapter. 

It  will  be  observed  that  I  quote  very  largely  from  the  writings 
of  my  American  confreres  in  the  specialty.  No  excuse  is  needed 
for  this  procedure,  because  from  no  quarter  have  we  derived,  in 
these  later  days,  so  many  original  observations  and  suggestions  of 
real  practical  value  as  from  the  members  of  the  American  Laryn- 
gological  Association. 

One  word  more — to  avoid  reiteration,  it  is  to  be  noted  that 
allusion  to  *  colleagues '  refers  always  to  my  co-workers  on  the 
surgical  staff  of  the  Central  London  Throat  and  Ear  Hospital, 
who,  in  addition  to  a  willingness  at  all  times  to  give  me  assistance 
in  my  own  work,  have  with  rare  liberality  and  unanimity  always 
drawn  my  attention  to  any  cases  of  unusual  interest  occurring  in 
their  own  practice. 

Lastly,  a  full  list  of  formulae  of  remedies  is  appended,  reference 
being  made  to  it  in  the  text  by  numerals  corresponding  to  those 
affixed  to  the  formulae. 

REFERENCES  TO  AUTHORITIES. 


PAGE. 


NO. 


Von  Ziemssen. 
Elsberg. 


TITLE  OF  WORK  REFERRED  TO. 


Dcutsches  Archiv  fur  Kliiiische  Med.^ 
vol.  xiii.,  1874. 
J  Archives  of  Laryngology,  New  York, 
(     vol.  i.,  p.  364. 


CHAPTER  1. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  THROAT  AND  NOSE. 

Although  it  is  beyond  the  scope  of  this  work,  written  as  it  is  for 
advanced  students  and  practitioners  of  medicine,  to  discuss  in 
detail  the  anatomy  and  physiology  of  the  larynx,  some  brief 
account  of  its  structure  and  uses  is  essential  to  a  right  compre- 
hension of  the  laryngoscopic  image,  as  well  as  of  the  changes 
made  by  disease  both  in  tissue  and  function,  as  viewed  with  the 
larynge.J  mirror.  For  the  same  reason,  it  will  be  necessary  to 
review  the  uw^ve  salient  features  of  the  anatomy  and  functions  of 
the  pharynX;  soft  palate,  nostrils,  etc. 

The  Larynx  may  be  described  as  a  box  composed  of  cartilages 
which  are  connected  by  ligaments  and  membranes,  and  acted 
upon  by  various  muscles.  Commencing  at  the  base  of  the  tongue, 
it  extends  dovv^nwards  as  far  as  the  trachea,  constituting  the  first 
portion  of  the  respiratory  tract,  and  containing  the  organ  of 
voice. 

Anteriorly  it  is  almost  subcutaneous,  and  forms  the  well-known 
prominence  called  Adam's  apple,  or  Pomum  Adami  (Fig.  I.,  i) ; 
on  each  side  of  it  lie  the  great  vessels  of  the  neck,  and  its  pos- 
terior wall  forms  the  antero-inferior  boundary  of  the  pharynx.  In 
shape  this  voice-box  is  irregularly  triangular,  the  apex  being  in 
front,  the  base  behind.  It  is  open  below  and  above.  Below  it  is 
continuous  with  the  trachea  (Fig.  L,  14),  and  above  it  opens  into 
the  pharynx,  its  aperture  in  this  direction  being  closed  by  a  kind 
of  movable  lid — the  epiglottis  (Fig.  I.,  13). 

The  skeleton  of  the  larynx  is  constructed  of  nine  separate  parts, 
viz.,  four  cartilages,  the  thyroid  (Fig.  I.,  7),  cricoid  (Fig.  I.,  2),  and 
two  arytenoid  (Fig.  III.,  i  and  2);  one  principal  fibro-cartilage> 
the  epiglottis  (Fig.  I.,  13)  ;  and  four  smaller  fibro-cartilages.  those 
of  Wrisberg  (Fig.  VI.,  11  and  12)  and  of  Santorini  (Fig.  VI.,  g 
and  10),  two  of  each.  These  latter  are  of  little  practical  impor- 
tance, being,  as  it  were,  merely  supplementary  to  the  arytenoids. 


ANATOMY  AND  PHYSIOLOGY. 


7 


^Luschka  further  describes  as  occasionally  present  one  inter-ary- 
tenoid  cartilage ;  and  as  more  frequently  existing,  two  pairs  of 
small  cartilages,  the  sesamoideae  anteriores  and  posteriores  (Fig. 
XII.,  II  and  12).  The  four  first-named  cartilages  are  liable  to 
ossification  as  the  result  of  age  or  disease,  but  the  epiglottis  and 
other  fibro-cartilages  never  undergo  this  process.  The  various 
cartilages,  large  and  small,  are  connected  by  ligaments,  and  by  a 
variety  of  articulations  are  capable  of  many  movements. 


Fig.  I.— Side  View  of  the  Larynx. 


1.  Prominence  of  thyroid  cartilage  (Pomum 

Adami). 

2.  Cricoid  cartilage. 

3.  4.  Upper  border  of  cricoid. 
5,  6.  Lower  border  of  cricoid. 
7.  Thyroid  cartilage. 


8,  9.  Superior  cornua  of  thyroid. 

10.  Right  inferior  cornua  of  thyroid. 

11.  Articulation  of  the  thyroid  with  the 

cricoid. 

12.  Crico-thyroid  aperture. 

13.  Epiglottis.    14.  Trachea. 


The  Thyroid  cartilage  {6vp€o<;,  a  shield)  is  the  largest  of  the 
laryngeal  cartilages  (Fig.  I.,  7,  and  Fig.  11.,  12  and  13),  and 
is  well  named  the  shield  of  the  voice-box,  containing  and  pro- 
tecting as  it  does,  the  essential  parts  of  the  vocal  organ — the 
vocal  cords.  Latterly  ^C.  Ludwig  has  called  it  the  ^  Stretching  ' 
cartilage,  because  the  tension  of  the  vocal  cords  is  dependent  on 
the  lever-like  movements  of  the  thyroid  cartilage.  It  is  composed 
of  two  alse  or  wings,  united  anteriorly  at  a  sharp  angle  by  a  centre- 
piece, the  lamina  mediana  cartilaginis  thyroideas  (Fig.  I.,  i),  which 
is  found  at  every  age  and  in  both  sexes.     The  vocal  cords 


8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


(Fig.  III.,  6,  3,  3),  as  well  as  the  thyro-arytenoidei  interni  muscles, 
are  attached  to  this  median  lamina.  The  wings  of  the  thyroid 
^Fig.  II.,  12,  13),  expanding  outwards  and  backwards,  form  the 
two  lateral  walls  of  the  larynx.  Their  superior  horns  or  cornua 
(Fig.  II.,  I,  2),  are  connected  with  the  hyoid  bone  (Fig.  II.,  5)  by 
the  thyro-hyoid  ligaments;  and  the  thyro-hyoid  membrane  extending 
between  the  cornua  and  the  hyoid  bone  serves  to  still  more  closely 
connect  these  two  structures.  The  epiglottis  (Fig.  II.,  10,  11)  is 
attached  at  its  posterior  aspect  to  the  superior  margin  by  the  thyro- 
epiglottic ligament,  while  inferiorly  the  thyroid  and  cricoid  carti- 


FiG.  II— Front  View  of  Larynx. 


1,2.  Superior  cornua  of  thyroid.  lo,  ii.  Epiglottis. 

3,4.  Inferior  cornua  of  thyroid.  12,  13.  Ala  of  thyroid  cartilage. 

5.  Hyoid  bone.  14.  Cricoid  cartilage. 

6,  7.  Cornua  of  hyoid  bone.  15.  Crico-thyroid  membrane. 
8,  9.  Thyro-hyoid  ligaments.  16,  Trachea. 

lages  are  connected  by  that  most  important  surgical  structure, 
the  cricoid-thyroid  membrane  (Fig.  II.,  15).  Two  inferior  cornua 
of  the  thyroid  are  further  united  to  the  cricoid  by  capsular  liga- 
ments lined  with  synovial  membrane  (Fig.  II.,  3,  4)  ;  while  to  the 
arytenoids  the  thyroid  is  united  by  the  vocal  cords,  and  by  the 
thyro-arytenoid  muscles  (Fig.  IV.,  i,  2,  3,  4). 

The  Cricoid  cartilage  (Fig.  III.,  10)  receives  its  name  from  its 
ring -like  form  (/cpt/co?,  a  ring).  C.  Ludwig  calls  it  the  '  Founda- 
tion '  cartilage,  because  upon  it  is  built,  as  it  were,  the  whole 
framework  of  the  larynx.    As  we  have  seen,  the  thyroid  rests 


ANATOMY  AND  PHYSIOLOGY.  g 

upon  it  by  its  inferior  cornua  (Fig.  11. ,  3,  4),  and  on  it  rotate  the 
arytenoid  cartilages  (Fig.  III.,  i,  2).  It  may  also  be  considered 
as  the  capital  of  the  column  of  the  trachea,  with  which  it  is  con- 
nected by  fibrous  tissue  (Fig.  I.,  5,  6).  It  is  narrow,  in  a  vertical 
direction  anteriorly,  but  broad  and  deep  behind.  Continuing  the 
comparison  to  a  signet  ring,  the  part  corresponding  to  the  seal  is 
thus  seen  to  be  placed  posteriorly.  The  lower  rim  of  the  cartilage 
(Fig.  I.,  5,  6)  is  nearly  horizontal  in  position,  but  its  upper  margin 
(Fig.  L,  3,  4),  from  the  greater  depth  of  the  posterior  part  inclines 
from  before  upwards  and  backwards.    The  posterior  part  of  the 


9 


Fig.  III.— Side  View  of  Larynx,  showing  the  Interior,  the  Right  Plate 
OF  the  Thyroid  being  removed. 

I,  2.  Arytenoid  cartilages.  7.  Facet  for  articulation  of  the  thyroid 

3,  3.  Process!  vocales  of  the  arytenoids.  with  the  cricoid. 

4.  Processus  musculus  of  the  right  ary-       8.  Left  plate  of  the  thyroid. 

tenoid.  9.  Left  superior  cornu  of  thyroid. 

5.  Upper  border  of  cricoid.  10.  Cricoid  cartilage. 

6,  3'  3-  Vocal  cords.  11.  Trachea. 

cricoid,  the  lamina  cartilaginis  cricoidcUy  is  hexagonal  in  shape, 
neither  the  sides  nor  the  angles,  however,  being  exactly  similar, 
although  the  two  halves  are  symmetrical.  In  the  median  line 
behind  and  internally  is  an  elevated  ridge  which  separates  two 
slight  depressions  for  the  insertion  of  the  posterior  crico-aryte- 
noid  muscles,  and  serves  for  the  attachment  for  the  oesophageal 
aponeurosis ;  while  in  front  there  is  a  notch,  the  space  between 
this  part  of  the  cartilage  and  the  thyroid  being  filled  in,  as  already 
stated,  by  the  crico-thyroid  membrane  (Fig.  XL,  15).  On  its  pos- 
terior and  superior  aspects  it  presents  two  broad  saddle-shaped 
articular  facets  for  the  reception  of  the  bases  of  the  arytenoid 


lO 


DISEASES  OF  THE  THROAT  AND  NOSE. 


cartilages.  Further,  the  cricoid  cartilage  marks  the  level  of  the 
commencement  of  the  oesophagus,  and  is  surgically  interesting 
from  the  fact  that  its  posterior  surface  offers  the  only  point  of 
resistance  in  the  anterior  part  of  the  gullet,  and  is  (probably  on 
this  account)  a  favourite  seat  of  malignant  ulceration. 

The  Arytenoid  cartilages  (Fig.  III.,  i  and  2),  two  in  number, 
are  pyramidal  in  shape,  their  apices  pointing  upwards  and  inwards, 
and  when  joined  together  they  bear  a  fanciful  resemblance  to  a 
pitcher  {apvTaiva) .  Situated  at  the  back  of  the  larynx,  they  arti- 
culate by  their  bases,  which  are  concave  from  before  backwards, 
with  the  articular  facets  already  described,  on  the  upper  and 


Fig.  IV.— Side  View  ok  the  Larynx,  showing  the  iNTERioa 
OF  the  Left  Half. 

I,  2,  3,  4-  Left  vocal  cord  and  the  thyro-      5.  Left  arytenoid  cartilage, 
arytenoideus  muscle.  6,  7.  Cricoid  cartilage. 

5,  7.  Crico  arytenoideus  lateralis  muscle. 

posterior  part  of  the  cricoid  (Fig.  III.,  4).  Ludwig  calls  the 
arytenoids  the  '  Regulating '  cartilages  (Stellknorpd),  because  on 
their  position  depends  the  shape  of  the  chink  of  the  glottis.  The 
base  of  the  arytenoid,  by  means  of  which  it  articulates  with  the 
cricoid,  is  prolonged  into  two  distinct  processes.  One,  the  pos- 
terior or  external  (Fig.  III.,  4),  has  the  shape  of  a  hook,  and  not 
only  gives  attachment  to  the  crico-arytenoid  muscles  (both  posticus 
and  lateralis),  acting  as  a  lever,  but  it  also  answers  the  purpose  of 
securing  the  position  of  the  arytenoid  on  the  cricoid  cartilage. 
Luschka  calls  it  accordingly  the  processus  musculo-articularis.  The 
anterior  part  of  the  bases  of  the  arytenoids— the  j^roc^rss^/s  vocalh 


ANATOMY  AND  PHYSIOLOGY. 


II 


(Fig.  III.,  3,  3) — is  a  projection  the  point  of  which  may  be  per- 
ceived with  the  laryngoscope  as  a  yellow  spot  visible  through 
the  mucous  membrane  of  the  vocal  cords  to  which  this  process 
gives  attachment.  The  arytenoid  cartilages  are  connected  at 
their  apices  with  the  epiglottis  by  means  of  the  aryteno-epiglot- 
tidean — or,  for  brevity,  the  ary-epiglottic  folds  (Fig.  VI.,  11,  13, 
and  12,  14),  and  with  the  thyroid  (in  addition  to  the  bond  of 
union  afforded  by  the  vocal  cords)  by  the  thyro-arytenoid  liga- 


FiG.  V. — Side  View  of  the  Larynx,  showing  the  Left  Ventricle  of 

MORGAGNI  AND  THE  LeFT  ARY-EpIGLOTTIC  LiGAMENT. 


I,  2.  Left  vocal  cord. 

3.  Elevation  indicating  the  site  of  the  left 

cartilage  of  Santorini. 

4,  5,  2,  I.  Entrance  to  left  ventricle  of  Mor- 

gagni. 

4,  5.  Left   ventricular  band  (false  vocal 
cord). 


Elevation  indicating  the  site  of  the 
left  cartilage  of  Wrisberg,  with  the 
cuneiform  cartilage  running  down 
to  4. 

Aryteno  -  epiglottidean    (ary  -  epiglottic) 

ligament. 
Arytenoideus  muscle. 


ments  (ventricular  bands  or  false  vocal  cords,  Fig.  V.,  4,  5),  which 
are  attached  to  their  anterior  surface. 

The  Cartilages  of  Santorini  (Fig.  V.,  3)  are  situated  above  the 
upper  pointed  extremities  of  the  arytenoids.  They  are  conical  in 
shape,  small,  and  very  pliant.  Their  function  is  probably  to  pro- 
tect the  apices  of  the  arytenoid  cartilages  from  the  pressure  of  the 
epiglottis  during  deglutition,  and  to  prevent  that  cartilage  from  too 
completeb'  closing  the  air-way.  ^Elsberg  therefore  appropriately 
named  them  the  '  Buffer  cartilages.'  Their  use  will  be  better  under- 


12 


DISEASES  OF  THE  THROAT  AND  NOSE, 


stood  by  reference  to  the  larynx  of  the  ox,  where  it  will  be  seen 
that  they  effectively  prevent,  on  account  of  their  large  size,  any 
very  extensive  lid-like  action  on  the  part  of  the  epiglottis. 

The  Cartilages  of  Wrisberg  (Fig.  VL,  ii,  12),  or  the  cuneiform 
cartilages  (Fig.  VL,  18,  19),  are  two  little  wedge-shaped  bodies 
embedded  in  the  ary-epiglottic  fold  (Fig.  VI. ,  11,  13,  and  12, 14)  in 
front  of  the  arytenoids,  and  are  surrounded  by  the  glands  of  Mor- 
gagni.  They  terminate  above  in  two  rounded  projections  imme- 
diately in  front  of  the  cartilages  of  Santorini  (Fig.  VI.,  g  and  10), 


7  and  8.  Superior   Thyro- arytenoid   liga-      17.  Cushion  of  epiglottis. 

ments  (ventricular  bands).  iS  and  19.  Cuneiform  cartilages. 

and  their  lower  ends,  according  to  some  writers,  dwindle  away  in 
the  direction  of  the  anterior  margin  of  the  arytenoids ;  while 
others  ascribe  to  them  the  shape  of  the  letter  L,  the  horizontal 
arm  of  which  follows  the  direction  of  the  vocal  cords  (Fig.  VI. , 
5  and  6). 

^Bland  Sutton  has  shown  that  the  cartilages  of  Santorini  and 
Wrisberg  are  vestigial  structures  representing  lateral  extensions 
of  the  epiglottis  which  pass  back  to  the  arytenoid  regicn  in  some 
of  the  lower  mammals. 


Fig.  VL — View  of  the  Larynx  Opened  from  Behind. 


I,  2.  Cricoid  cartilage. 

3,  4.  Arytenoideus  muscle  (cutaneous). 

5  and  6.  Vocal  cords. 

5,  7,  6,  8.  Entrances  to  ventricles  cf  Mor- 


9  and  10.  Cartilages  of  Santorini. 
II  and  12.  Cartilages  of  Wrisberg. 
II,  13,  and  12,  14.  Aryteno-epiglottidean 


(ary-epiglottic)  ligaments. 
15.  Epiglottis.    16.  Trachea. 


gagni. 


ANATOMY  AND  PHYSIOLOGY. 


13 


The  Posterior  sesamoid  cartilages,  discovered  by  Luschka, 
are  not  invariably  present,  but,  being  frequently  found  in  both 
sexes,  they  nevertheless  deserve  some  notice.  They  are  very 
small,  oblong  in  shape,  and  are  attached,  by  means  of  delicate 
ligaments,  above  to  the  cartilages  of  Santorini,  and  below  to  the 
arytenoids.  Their  position  is  close  to  the  lateral  margin  of  the 
arytenoid  cartilages,  where  these  are  surmounted  by  the  cartilages 
of  Santorini. 

The  Anterior  sesamoid  cartilages  (Fig.  XII.,  11  and  12),  each 
scarcely  larger  than  the  head  of  a  pin,  are  embedded  in  the 
anterior  part  of  the  vocal  cords,  and  they  are  united  to  the 
thyroid  by  means  of  a  tough  tissue  which  never  ossifies,  and 
which  serves  as  a  point  of  attachment  not  only  for  the  vocal 
cords,  but  also  for  the  thyro-arytenoidei  interni  muscles.  The 
existence  of  the  anterior  sesamoid  cartilages  is  the  rule  rather 
than  the  exception. 

The  Inter-arytenoid  cartilage  is  a  little  body  v;hich  is  some- 
times found  between  the  arytenoids.  It  was  first  noticed  by 
Luschka,  who  describes  a  case  in  which  it  had  the  appearance  of 
a  yellowish  prominence,  that  might  easily  have  been  mistaken 
for  an  abscess  when  seen  with  the  laryngoscope.  It  is  but  very 
exceptionally  present. 

The  Epiglottis  (Fig.  VI.,  15)  is  a  single  leaf-like  piece  of  yellow 
fibro-cartilage,  resembling  an  obovate  leaf.  It  is  sometimes 
described  as  being  connected  to  the  base  of  the  tongue  by  three 
glosso-epiglottidean  ligaments.  On  laryngoscopic  and  other 
inspection  three  folds  of  mucous  membrane,  one  central  and  two 
lateral,  can  undoubtedly  be  seen  passing  from  the  epiglottis  to 
the  base  of  the  tongue,  but  ^Mayo  Collier  has  recently  contended 
that  only  the  centre  one  of  these  folds  contains  any  ligamentous 
tissue,  the  two  lateral  ligaments  of  the  epiglottis  passing  not  to 
the  base  of  the  tongue,  but  to  join  that  part  of  the  pharyngeal 
aponeurosis  which  is  situated  externally  to  the  faucial  tonsils. 
The  organ  is  also  connected  to  the  arytenoid  region  by  two  folds 
of  mucous  membrane,  the  aryteno-epiglottidean  folds,  which  latter 
contain  the  cartilages  of  Wrisberg  and  Santorini  and  the  ary- 
epiglottici  muscles;  these  folds,  therefore,  like  the  opposing  lateral 
glosso-epiglottidean  folds,  are  potential,  though  not  true,  ligaments 
in  man,  as  they  contain  no  elastic  tissue.  The  true  ligaments 
usually  described,  and  readily  demonstrable,  are,  the  thyro- 
epiglottidean,  which  connects  the  lower  end  of  the  epiglottis  to 
the  notch  in  the  upper  border  of  the  thyroid  cartilage,  and  the 
hyo-epiglottidean  ligament,  which  passes  between  the  front  of  the 
epiglottis  and  the  whole  len^-th  of  the  hyoid  bone. 


14 


DISEASES  OF  THE  THROAT  AND  NOSE. 


A  good  deal  of  discussion  has  lately  taken  place  as  to  the  posi- 
tion, movements,  and  function  of  the  epiglottis.  In  a  paper  read 
at  the  International  Medical  Congress  at  Washington,  1877,  my 
colleague,  ^Mr.  Carmalt  Jones,  submitted  as  the  result  of  extended 
laryngoscopic  observations  that  the  epiglottis  did  not  shut  over  the 
larynx  like  a  lid  in  deglutition  as  commonly  held,  but  curled  in 
laterally  like  a  split  tube,  in  order  to  allow  the  food  to  pass  down 
by  its  sides  into  the  pyriform  fossae.  During  the  last  year  this 
subject  has  been  thrashed  out  at  the  Anatomical  Society,  with 
the  result  that  the  correctness  of  the  above  views  is  pretty 
generally  conceded,  and  the  greater  importance  of  the  epiglottis 
in  respiration  and  voice-production  insisted  on.  There  is  little 
doubt  that  the  soft  palate  above  and  the  epiglottis  below,  together 
form  a  partition  or  diaphragm  by  which  the  respiratory  air  is  shut 
off  from  the  oral  cavity  during  ordinary  normal  breathing  through 
the  nose.  The  upright  position  of  the  epiglottis  enables  it  to  act 
as  a  wall,  which  prevents  the  oral  and  nasal  secretions  entering 
the  larynx.  '^Professor  Howse,  from  the  fact  that  the  epiglottis 
exceptionally  occupies  an  intra-narial  position  in  some  animals, 
argues  that  this  is  the  primitive  condition  of  the  organ.  This  is 
probably  going  too  -^ar.  It  is  curious  that  the  epiglottis  is 
essentially  a  mammalian  structure;  only  a  few  birds,  such  as  the 
swan,  possessing  even  a  rudimentary  organ,  and  it  must  be  re- 
membered that  in  birds  the  larynx  is  not  the  organ  of  voice. 

The  correspondence  between  ^Dr.  Foulis,  and  '-^Dr.  Howard, 
^^Dr.  Bowles  and  others,  has  brought  out  the  fact  that  the 
epiglottis,  except  for  the  action  of  the  ary-epiglottidean  muscles 
on  its  lateral  margins,  is  not  a  very  movable  organ  in  itself. 
There  is  no  doubt  that  it  can  be  raised  by  direct  traction  on  the 
hyoid  bone  through  the  hyo-epiglottidean  ligament,  or  indirectly 
through  the  action  of  the  muscles  which  pass  from  that  bone  to 
the  tongue  and  jaw;  but  Howard's  method  of  extreme  extension 
of  the  neck  to  relieve  respiratory  troubles  during  anaesthesia  is 
scarcely  likely  to  find  favour  as  the  '  only  true  way  '  of  giving 
such  relief  in  operations  performed  on  the  throat  and  nose,  for 
the  very  simple  reason  that  Howard's  method  presupposes  the 
absence  of  marked  nasal  obstruction,  a  factor  complicating 
probably  three  out  of  four  patients  operated  on  in  this  special 
domain. 

The  cavity  of  the  larynx  is  divided  into  three  compartments ; 
the  first  and  largest  (supra-glottic)  is  that  which  lies  above  the 
ventricular  bands,  and  is  heart-shaped,  the  broader  part  being 
situated  anteriorly  and  corresponding  to  the  line  of  the  epiglottis, 


ANATOMY  AND  PHYSIOLOGY. 


15 


the  lateral  walls  being  formed  by  the  folds  connecting  the  epi- 
glottis with  the  arytenoid  cartilages. 

The  second  or  glottic  division  is  that  part  which  comprises  the 
ventricular  bands  (Fig.  VL,  7  and  8),  the  vocal  cords  (Fig.  VI.,  5 
and  6),  and  the  ventricles  of  Morgagni. 

The  Ventricular  Bands,  formerly  called  false  vocal  cords,  are 
longitudinal  glandular  folds  of  mucous  membrane  containing  a 
little  fibrous  tissue  (superior  thyro-arytenoid  ligaments).  An- 
teriorly they  are  attached  to  the  thyroid  (Fig.  V.,  5)  and  posteriorly 
to  the  anterior  surface  of  the  arytenoid  cartilages.  They  are 
capable  of  being  closely  approximated,  and  by  this  means  the 
upper  division  of  the  cavity  of  the  larynx  is  separated  from  the 
two  lower  ones,  thus  forming  a  narrow  tube  with  a  closed  bottom. 
This  closure  of  the  ventricular  bands  takes  place  at  the  moment 
of  deglutition,  and  in  many  other  muscular  efforts,  such  as  in 
coughing,  straining,  and  bearing  down. 

The  Vocal  Cords,  bands,  tongues,  reeds,  ligaments,  or  lips 
(Figs,  v.,  I,  2  and  VL,  5  and  6),  as  they  have  been  variously  called, 
and  which  are,  in  fact,  the  inferior  thyro-arytenoid  ligaments,  are 
two  ledges  or  bands  composed  of  yellow  elastic  tissue,  covered 
with  a  thin,  closely  adherent  layer  of  mucous  membrane,  and 
admitting  of  elongation  and  contraction  according  to  the  relative 
position  of  the  cartilages  from  which  they  spring.  Their  length, 
'  when  at  rest,  is  in  the  male  about  three-fourths  of  an  inch  ;  in  the 
female  about  half  an  inch.  The  exact  attachments  of  the  cords  to 
the  thyroid  and  to  the  arytenoids  respectively  have  been  explained 
above,  but  it  has  to  be  noted  that  they  are  in  no  sense  of  the 
nature  of  strings.  Their  contour  on  section  is  not  round  but 
triangular,  and  their  shape  is  therefore  that  of  a  prism  ;  the  bases 
are  firmly  attached  along  their  whole  length  to  the  thyroid  carti- 
lages, and  neither  the  superior  nor  inferior  surfaces  are  entirely 
free,  only  their  thin  opposing  edges — that  portion  which  would  on 
section  constitute  the  apices  of  the  triangles.  In  strong  contrast 
with  the  red  ventricular  bands  the  vocal  cords  are  white,  and  this 
is  particularly  well  marked  in  women.  Bland  Sutton  has  recently 
put  forth  the  view  that  the  vocal  cords  are  morphologically  really 
only  the  metamorphosed  inner  edges  of  the  thyro-arytenoid 
muscles  which  have  become  tendinous,  in  order  to  give  a  central 
attachment  to  some  of  the  muscular  fibres  and  as  better  adapted 
to  vocal  function.  The  yellow  elastic  tissue,  a  special  charactei- 
istic  of  these  tendons,  is  necessary  for  the  due  maintenance  of 
tension  without  muscular  effort,  and  obviates  the  *  wrinkling ' 
which  would  otherwise  follow  on  relaxation  of  the  structure. 


i6  DISEASES  OF  THE  THROAT  AND  NOSE. 

The  Ventricles  of  Morgagni  (Fig.  VI.,  5,  7  and  6,  8)  are  two 

pockets  or  pouches  in  the  lateral  walls  of  the  cavity  of  the  larynx, 
the  entrances  to  which  are  bounded  above  by  the  ventricular  bands 
and  below  by  the  vocal  cords.  They  are  oblong  in  shape,  and 
vary  very  greatly  in  size  in  different  individuals.  They  do  not,  as 
a  rule,  reach  as  far  as  the  corresponding  part  of  the  upper  margin 
of  the  thyroid  cartilage,  but  occasionally  they  extend  beyond  it ; 
sometimes  indeed  they  may  be  traced  to  just  beneath  the  mucous 
membrane,  at  the  posterior  part  of  the  root  of  the  tongue.  The 
ventricles  are  invested  with  a  layer  of  cellular  tissue,  but  they  are 
also  partly  in  contact  with  fibres  of  the  thyro-arytenoid  (Fig.  IV., 
I,  2,  3,  4),  and  of  the  thyro-epiglottic  muscles.    They  are  more- 


FiG.  V1I.~The  Larynx  in  Gentle  Breathing. 


Fig.  VIII.— The    Larynx    in   Tone  Fig.  IX.— The  Larynx  in  Deep 

Production.  Breathing. 

T.  Tongue.  P,P.  Ventricularbands,  or  pocket  ligaments, 

V,  V.  Vocal  cord<?.  formerly  called  false  vocal  cords. 

W,  W.  Cartilages  of  Wrisberg.  •    B.  Bifurcation  of  trachea. 

L.  Epiglottis.  C.  Cushion  of  epiglottis. 

S,  S.  Cartilages  of  Santorini. 

over  surrounded  by  muciparous  glands  and  a  large  amount  of 
lymphoid  tissue  ('  laryngeal  tonsil '  of  ^^Hill),  which  reach  down 
to  the  lateral  attachments  of  the  surface  of  the  vocal  cords.  A 
further  account  of  the  glandular  structures  of  the  ventricle  will  be 
found  at  chap.  xii. 

The  Sacculus  laryngis  is  a  small  unimportant  vestigial  structure 
in  man,  representing  those  air  sacs  which  extend  from  the  larynx 
over  the  front  of  the  neck  and  chest,  even  as  far  as  the  armpits,  in 
anthropoid  and  other  apes. 

The  third,  or  infra-glottic  division,  is  that  portion  of  the  larynx 
which  extends  from  the  inferior  surface  of  the  vocal  cords  to  the 
lower  border  of  the  cricoid — the  beginning  of  the  trachea.  The 
second  division  of  the  larynx  is,  in  the  physiological  as  well  as  in 


ANATOMY  AND  PHYSIOLOGY, 


17 


a  clinical  sense,  the  most  important  of  the  three  ;  for  not  only  by 
the  action  of  air  expired  from  the  lungs  on  to  the  vocal  cords  is 
vocal  sound  actually  produced,  but  these  same  vocal  cords  play  a 
prominent  part  in  the  function  of  respiration.  This  narrow  orifice 
may  well  be  termed  '  the  portal  of  the  breath  of  life.'  Technically, 
it  is  called  the  Glottis,  or,  more  correctly,  Rima  Glottidis  (chink 
of  the  glottis).  The  rima  glottidis  in  repose  is  more  or  less 
elliptical  in  shape  {see  Plate  X.,  Fig.  92  ;  and  Fig.  VII.),  longer  in 
the  male  than  in  the  female,  measuring  nearly  one  inch  in  the 
former  and  two  or  three  lines  less  in  the  latter.  The  form  of  the 
rima  glottidis  varies  greatly  in  different  actions  of  the  cords,  being 
almost  closed  in  the  production  of  certain  vocal  notes  (Fig.  VIII.), 
while  in  full  inspiration  its  form  is  irregularly  triangular  (Fig. 
IX.),  the  apex  being  anteriorly  at  the  thyroid  angle,  whence  the 
vocal  cords  arise  (anterior  commissure  of  the  vocal  cords) ;  the 
two  posterior  angles  at  the  arytenoid  cartilages,  where  the  same 
cords  are  inserted,  the  base,  which  is  somewhat  curved,  being 
formed  b}'  the  space  between  these  cartilages  (inter-arytenoid 
space,  or  posterior  commissure  of  the  vocal  cords). 

We  have  now  to  treat  of  the  functional  movements  of  the  vocal 
cords,  which  are  regulated  by  certain  muscles. 

Of  these  it  will  be  sufficient  to  enumerate  those  known  as  the 
intrinsic  muscles  of  the  larynx,  which  may  be  classified  somewhat 
as  follows  : 

ACTION  OF  MUSCLES. 

I.— Narrowing  the  Vesjibule. 

r,.,  •  1         •       (  Arv-epiglottici 

1  hyro-ary-epiglottiaei      -      '         .  .        n^.  f 

^        ^    ^  I  i  hyio-epiglottidei      -  Kespiratory. 

Arytenoideus  -J 

II.— Governing  the  Shape  of  the  Rima  Glottidis. 

Thyro-arytenoidei  ex-  and  interni  . 

^  .         ^      -J  •  1  .     1  [Close  true  glottis       -       -  C  ,t  , 

Cnco-arytenoidei  lateiales         -  j  ^  ^  Vocal  and  respiratory. 

Arytenoideus    -       -       .       -     closes  cartilaginous  glottis  -  j 

Crico-arytenoidei  postici   -       -     open  glottis       -       -       -  Respiratory. 

III.— Governing  the  Pitch  of  the  Voice. 
Ci  ico-thyroidei  .       -       -       -     Tense  the  vocal  cords. 

]  Shorten,  relax,  and  bring  in  apposition  the  vocal 
Thyro-arytenoidei  interni  -      .  -  r  cords. 

The  Crico-arytenoidei  postici  (Fig.  X.,  18  and  19)  are  the 

separators  or  abductors  of  the  vocal  cords,  and  are  called  into 
action  on  inspiration.  They  are  two  triangular  muscles,  the  bases 
of  which  are  attached  to  the  posterior  part  of  the  cricoid  carti- 
lage, from  which  origin  they  converge  upwards  and  outwards  in 

2 


DISEASES  OF  THE  THROAT  AND  NOSE. 


such  a  manner  as  eventually  to  grasp  the  processus  rnusculares  of 
the  arytenoids  (Fig.  III.,  4).  By  drawing  these  backwards  and 
inwards  the  processus  vocales  (Fig.  III.,  3)  are  moved  outwards, 
and  the  rima  glottidis  is  thus  thrown  open.  The  extent  to  which 
this  takes  place  depends,  of  course,  upon  the  varying  requirements 
of  deep  or  ordinary  respiration. 

i-Carl  Merkel  and  i^Professor  Turner  have  described  an  occa- 
sional additional  muscle  of  the  larynx  which  when  present  exists 
asymmetrically,  i.e.,  only  on  one  side.    It  arises  close  to  the 


origin  of  the  outer  or  anterior  fibres  of  the  crico-arytenoideus 
posticus,  so  that  it  appears  as  an  additional  portion  of  the  same. 
It  does  not,  however,  pass  upwards  with  this  last  muscle,  but 
extends  obliquely  upwards  and  outwards,  and  after  a  short  course 
is  attached  to  the  posterior  margin  of  the  inferior  horn  of  the 
thyroid  cartilages.  The  inferior  laryngeal  nerve  passes  under  it, 
and  the  kerato-cricoid  ligament  crosses  it  at  nearly  a  right  angle. 
The  entire  muscle  is  about  3-4'"  long,  and  it  has  received  the 
name  of  the  Kerato-cricoid.  Merkel  does  not  attach  importance 
to  its  action,  which  is  supposed  to  fix  the  lower  horn  of  the  thyroid 


Fig,  X.— Thf.  Muscles  cf  the  Larxyx  sf.kx  from  Behind. 


T,  2.  Cricoid  cartilage. 
3,  4.  Arytenoideus  muscle. 
5  and  6.  Thyroid  cartilage. 
7,  8.  Hyoid  bone. 

9  and  12.  Cartilages  of  Santorini. 

10  and  13.  Cartilages  of  Wrisberg. 


1 1,  15,  14.  Epiglottis. 
10.  Trachea. 

17.  Thicker  (cushion)  portion  of  epiglottis. 
\S  and  19.  Crico-arytenoidei  posterior  muscles. 
20,  21  and  22,  23.  Arytenoidei  constrictores 


vestibuli  laryngis  muscles. 


ANATOMY  AND  PHYSIOLOGY. 


19 


backwards  and  downwards,  and  thus  to  oppose  in  some  measure 
the  portion  of  the  crico-thyroid  muscle  connected  to  the  anterior 
margin  of  the  horn.  The  frequency  of  appearance  of  this  muscle 
is  given  by  Turner  as  about  21  per  cent.  The  same  observer's 
examination  modifies  Merkel's  statement  that  the  muscle  is 
always  unilateral. 

The  Crico-arytenoidei  laterales  (Fig.  IV.,  5,  7)  have  their 
origin  along  the  upper  border  and  on  the  outer  surface  of  the  sides 
of  the  cricoid  cartilage,  and  they  are  directed  obliquely  upwards 
and  backwards,  to  be  inserted  into  the  outer  angles  of  the  bases 
(the  processi  musculares)  of  the  arytenoid  cartilages  (Fig.  III.,  4). 
The  action  of  these  muscles  is  to  rotate  the  processi  vocales 
(Fig.  III. 5  3)  inwards,  thereby  approximating  the  vocal  cords  in 
phonation. 

The  Arytenoideus  (Fig.  X.,  3,  4)  is  a  square  muscle,  which  is 
attached  to  the  posterior  concave  aspect  of  the  arytenoid  carti- 
lages, and  it  serves  to  assist  the  crico-arytenoidei  laterales  in 
closing  the  glottis.  If  the  action  of  the  arytenoideus  precedes 
that  of  the  crico-arytenoidei  laterales,  then  the  rima  glottidis  takes 
for  a  moment  a  rhomboid  shape  ;  if,  on  the  other  hand,  the  action 
of  the  crico-arytenoidei  laterales  precedes  that  of  the  arytenoi- 
deus, then  the  vocal  cords  will  be  approximated,  while  the  space 
between  the  arytenoid  cartilages  remains  open.  The  most  recent 
view  is  that  the  arytenoideus  represents  a  continuation  of  the 
thyro-arytenoideus,  and  that  it  further  exemplifies  the  existence 
of  a  sphincter  of  the  glottis. 

The  Thyro-arytenoidei  (Fig.  IV.,  i,  2,  3,  4)  are  broad  flat 
muscles  running  parallel  with  the  vocal  cords,  by  which  they  are 
partly  covered.  These  muscles  are  attached  posteriorly  to  the 
outer  borders,  lower  parts  of  outer  surfaces  and  vocal  processes 
of  the  arytenoid  cartilages,  and  anteriorly  to  the  receding  angle  of 
the  thyroid  cartilage  in  its  lower  half,  and  to  the  crico-thyroid 
membrane.  Various  sub-divisions  of  these  muscles  have  been  made, 
but  for  practical  purposes  it  is  sufficient  to  consider  only  two, 
namely,  the  external  and  the  internal.  When  the  thyro-ar3'tenoidei 
externi  contract  they  draw  forward  the  ar\tenoid  cartilages, 
thus  opposing  the  crico-thyroid  (Fig.  XL,  i,  2,  3),  and  thereby 
slackening  the  vocal  cords.  The  actions  of  the  crico-thyroidei 
and  the  thyro-arytenoidei  externi  are,  therefore,  antagonistic. 
The  former  are  tensors  or  elongators,  and  the  latter  shorteners  or 
relaxors,  of  the  vocal  cords.  The  thyro-arytenoidei  have,  how- 
ever, the  additional  important  function  of  moving  inward  the 
vocal  process,  thus  pressing  together  the  inner  edges  of  the  vocal 


20 


DISEASES  OF  THE  THROAT  AND  NOSE. 


cords  in  phonation,  while  the  special  purpose  of  the  internal  fibres 
which  pass  from  the  arytenoid  cartilage  to  the  cord  and  from  one 
part  of  the  cord  to  another,  is  to  regulate  the  finer  gradations  in 
the  shape  of  the  vocal  chink  during  singing.  The  thyro-aryte- 
noidei  have  been  called  the  vocal  muscles — a  name  which  they  well 
deserve,  for,  when  they  are  paralyzed,  total  loss  of  voice  is  the 
result.  Their  description  would  not  be  complete  without  men- 
tioning two  additional  external  bundles  of  fibres  which  pass  to  the 
epiglottis,  one  on  either  side,  which,  although  they  assist  in  nar- 
rowing the  rima  glottis,  are  said  also  to  approximate  the  ventri- 
cular bands  (Fig.  VI.,  7,  8),  compress  the  sacculus  laryngis,  and 
depress  the  epiglottis. 

The  Ary-epiglottici  (Fig.  X.,  20,  21,  and  22,  23)  are  two  thin 
flat  muscles  which,  arising  from  the  outer  and  posterior  border  of 
the  arytenoid  cartilages,  pass  upwards  and  over  to  the  opposite 
side  through  the  ary-epiglottic  folds  to  the  epiglottis,  encircling  in 
their  route  the  tapering  points  of  the  arytenoids  just  below  the 
cartilages  of  Santorini,  and  then  stretching  across  the  cuneiform 
cartilages.  These  muscles  have  received  the  names  of  the 
constriciores  vestibuli  laryngis.  They  tend  to  bring  together  the 
tips  of  the  arytenoid  cartilages  and  to  make  the  epiglottis  curve 
inwards  at  its  edges,  assuming  the  shape  somewhat  of  a  split 
tube  during  deglutition.  They  also  probably  exercise  the  same 
action,  and  perhaps  aid  in  depressing  the  upper  part  of  the  epi- 
glottis during  phonation. 

The  Crico-thyroidei  (Fig.  XL,  i,  2,  3)  are  the  only  intrinsic 
muscles  of  the  larynx  perceptible  from  the  outside  of  the  throat. 
Each  of  them  consists  of  two  bundles,  which  together  present  a 
fan-like  appearance.  Their  lower  ends  are  pointed,  and  arise 
from  the  antero-lateral  portions  of  the  cricoid  cartilage  ;  the 
fibres,  diverging,  pass  obliquely  upwards  and  backwards,  to  be 
inserted,  some  into  the  lower  borders  of  the  thyroid  cartilage,  and 
a  few  others  into  its  internal  and  external  surfaces  near  the 
borders.  The  action  of  these  muscles  is  to  draw  the  thyroid 
forwards  and  downwards,  thereby  putting  the  vocal  cords  on  the 
stretch.  i^Majendie,  in  1813,  maintained  a  contrary  opinion  of 
the  action  of  these  muscles,  asserting  that  they  draw  the  cricoid 
cartilage  up  towards  the  thyroid,  and  this  view  has  recently  been 
revived,  especially  by  ^^Hooper,  of  Boston,  who,  after  numerous 
experiments,  confirms  Majendie's  statements.  Practically  the 
point  is  not  one  of  great  importance,  since  the  eftect  of  the 
muscular  movement  is,  in  either  case,  equally  to  stretch  the  vocal 
cords.    The  latest  writer  on  this  subject,  ^^Desvernine,  says  that 


AN' ATOMY  AND  PHYSIOLOGY. 


21 


he  attributes  to  the  crico-thyroid  muscles  an  active  part  in 
regulating  both  the  longitudinal  and  transverse  diameter  of  the 
cords  :  '  If  the  larynx  is  in  the  respiratory  position  then  it  draws 
up  the  anterior  segment  of  the  cricoid,  the  arytenoid  is  depressed, 
the  free  border  of  the  bands  relaxed,  and  thus,  indirectly,  it  co- 
operates with  the  thyro-arytenoideus  to  their  transverse  tension. 
If,  on  the  contrary,  the  larynx  is  more  or  less  suspended,  then  its 
contraction  is  resolved  in  a  displacement,  backwards  and  upwards, 
of  the  cricoid,  the  bands  are  powerfully  elongated,  the  transverse 
diameter  reduced,  and  it  opposes  at  the  free  border  of  the  bands. 


through  the  thyro-arytenoid  ligament,  the  required  resistance  to 
the  impinging  blast  of  air.' 

The  arteries  which  supply  blood  to  the  larynx  are  branches 
derived  from  the  superior  and  inferior  thyroid,  the  former  of 
which  is  a  branch  of  the  external  carotid  and  the  latter  of  the 
thyroid  axis  from  the  subclavian. 

The  nerves  of  the  larynx  are  the  superior  laryngeal  and  the 
inferior  or  recurrent  laryngeal,  both  branches  of  the  pneumo- 
gastric,  the  motor  being  of  spinal  accessory  origin;  together 
with  a  few  filaments  from  the  sympathetic.  The  mucous 
membrane  of  the   larynx  and   the   crico-thyroid   muscles  are 


Fir,.  XL— Side  View  of  the  Larynx,  showing  the  Right 
Crico-thyroid  Muscle. 


1,  2,  3.  Crico-thyroideus  muscle.  6,  7.  Superior  cornua  of  thyroid. 

4.  Right  inferior  cornua  of  thyroid.  8.  Epiglottis. 

5.  Thyroid  cartilage.  9-  Trachea. 


22 


DISEASES  OF  THE  THROAT  AND  NOSE. 


supplied  by  the  superior  laryngeal,  and  the  remaining  muscles 
by  the  recurrent  laryngeal,  the  arytenoideus  receiving  filaments 
from  both.  It  is  essential  to  bear  in  mind  the  course  of  these 
recurrent  nerves,  which  is  not  the  same  on  both  sides.  On  the 
right  side  the  nerve  arises  in  front  of  the  subclavian  artery,  winds 
lound  that  vessel  from  before  backwards,  and  then  ascends 
obliquel}'  to  the  side  of  the  trachea  behind  the  common  carotid 
and  inferior  thyroid  arteries.  On  the  left  side  it  arises  in  front 
of  the  arch  of  the  aorta,  round  which  it  turns  to  gain  the  side  of 
the  trachea.  This  branch  of  lar3mgeal  anatomy,  and  especially 
the  physiological  aspect  of  laryngeal  innervation,  will  of  necessity 
be  referred  to  in  greater  detail  when  treating  of  the  '  Neuroses  of 
the  Larynx.' 


Fig.  XII. 


-ViKW  OF  A  Section  of  the  Larynx  from  Abov 


I,  2.  Processi  musculares  of  the  arytenoids, 

3,  3.  Cricoid  cartilage. 

4,  I  and  5,  2.  Posterior  crico-arytenoidei 

muscles. 

6,  7,  Proces.  i  vocales  of  arytenoids. 
6,  II  and  7,  12.  Vocal  cords, 
o.  Arytenoideus  muscle. 


9  and  10.  Elsberg's  '  vocal  nodules. 
II  and  12.  Sesamoid  cartilages. 
13  and  14.  Thyroid  cartilage. 
15   and    16.    Crico-arytenoidei  laterales 
mu-cles. 

17  and  18.  Thyro-arytenoidei  muscles. 
19  and  20.  Crico-arytenoid  ligaments. 


The  Mucous  Membrane  of  the  larynx  is  continuous  with  that 
of  the  mouth  and  pharynx,  and  extends  along  the  trachea  to  the 
minute  bronchi.  The  epithelium  is  of  the  ciliated  variety,  except 
over  a  portion  of  the  epiglottis,  the  upper  surface  of  the  ventri- 
cular bands,  and  over  the  vocal  cords,  where  it  is  squamous.  The 
laryngeal  mucous  membrane  is  studded  with  numerous  muci- 
parous glands,  which  exist  in  especially  large  numbers  on  the 
epiglottis,  the  ary-epiglottic  fold,  and  the  inner  surface  of  the 
sacculus  laryngis,  while  on  the  vocal  cords   none  are  found. 

Heitler  has  found  lymphoid  tissue  in  the  ary-epiglottic  folds,  and 
in  the  mucous  membrane  covering  the  arytenoid  cartilages.  There 
is  a  large  aggregation  lining  the  ventricle,  to  which  Hill  has  given 
the  name  of  the  laryngeal  tonsil,  on  the  ground  that  its  function 
is  analogous  to  that  of  the  faucial  tonsil,  namely,  the  secretion  of 


ANATOMY  AND  PHYSIOLOGY. 


23 


scavenging-  leucocytes  for,  in  this  case,  the  removal  of  small  par- 
ticles— e.g.,  dust  and  germs  from  the  vocal  cords.  Surgically  the 
laryngeal  mucous  lining  is  of  importance  in  relation  to  its  varying 
thickness  and  amount  of  submucous  tissue  in  different  situations, 
and  the  consequently  varying  liability  of  different  portions  to 
inflammation  and  serous  infiltration  (oedema). 

The  portions  so  liable  are  in  order  of  degree  the  ary-epiglottic 
folds,  the  ventricular  bands  and  ventricles,  and  the  inferior  laryn 
geal  surface  of  the  epiglottis.    The  lymphatics  of  this  region  empty 
themselves  into  the  deep  cervical  glands — they  are  described  more 
fully  at  Chapter  XXII.  in  their  relation  to  malignant  disease. 

The  Trachea  (.Fig.  I.,  14)  extends  from  the  cricoid  cartilage  to 
its  bifurcation  opposite  the  fourth  dorsal  vertebra.  It  is  about 
four  and  a  half  inches  in  length,  and  three-quarters  of  an  inch  in 
breadth,  and  is  convex  in  front,  but  somewhat  flattened  behind. 
It  is  built  up  of  cartilaginous  rings,  regular  above,  irregular  below, 
from  sixteen  to  twenty  in  number.  The  latter  do  not  meet 
posteriorly,  but  are  connected  by  fibrous  tissue,  as  well  as  by 
bands  of  muscular  fibre,  whose  contraction  serve  to  materially 
lessen  the  calibre  of  the  tube.  The  lining  mucous  membrane  is 
covered  with  columnar  ciliated  epithelium,  and  contains  much 
lymphoid  and  mucous  glandular  tissue. 

It  divides  into  two  bronchi,  one  for  each  lung,  that  for  the 
right  being  the  larger  of  the  two.  Foreign  bodies  falling  dov/n 
the  tube  are  generally  said  to  drop  into  the  right  bronchus.  From 
some  recent  statistics  made  by  ^^Cheadle,  however,  it  would 
appear  that  they  as  frequently  pass  down  the  left.  It  must  be 
remembered  that  the  right  bronchus,  though  the  larger,  is  also  the 
more  horizontal,  but  the  left  runs  more  nearly  in  the  same 
direction  as  the  trachea.  Bodies  would  no  doubt  always  go  to 
the  left  were  it  not  that  the  pathway  in  that  din^ction  is  smaller, 
and  that  the  septum  marking  the  division  of  the  two  bronchi,  is 
situated  to  the  left  of  the  tracheal  axis,  so  that  bodies  hitting  this 
septum  are  often  diverted  into  the  larger  right  bronchus. 

While  the  essential  function  of  the  larynx  is,  as  its  name 
implies,  in  reference  to  phonation  or  voice-production,  it  has 
certain  duties  to  perform  in  the  course  of  deglutition  and  respira- 
tion. During  the  passage  of  food  over  its  superior  aperture,  the 
whole  organ  is  drawn  upwards  and  forwards  under  the  base  of 
the  tongue,  following  to  some  extent  the  movements  of  the  hyoid 
bone,  to  which,  as  has  been  seen,  it  is  attached  by  ligamentous 
and  muscular  structures.  The  epiglottis  (Fig.  XL,  8)  is  curled 
laterail}^  forming  a  narrow  tubular  entrance  for  air  from  the  nose 


24 


DISEASES  OE  THE  THROAT  AND  NOSE. 


to  the  larynx,  and  lid-like  closure  is  somewhat  prevented  by  the 
presence  of  the  cartilages  of  Santorini  (Fig.  X.,  g  and  12). 
Approximation  of  the  ventricular  bands  also  takes  place,  together 
with  a  constriction  of  the  vestibule  or  first  part  of  the  larynx,  to 
aid,  and  in  some  cases  to  replace,  the  action  of  the  epiglottis. 

During  respiration  a  rhythmical  movement  of  the  vocal  cords 
takes  place,  the  rima  glottidis,  or  interval  between  the  cords,  en- 
larging during  inspiration  and  becoming  smaller  during  expiration. 

It  may  be  noted  as  a  clinical  fact  that  if  inspiration  be  unduly 
forced,  the  rima,  as  seen  by  the  laryngoscope,  is  in  such  circum- 
stances frequently  narrowed  rather  than  increased.  This  may  be 
due  either  to  the  opposing  muscles  being  brought  into  play,  or 
simply  to  the  impact  of  air  on  the  concave  upper  surfaces  of  the 
cords  leading  to  an  approximation  of  the  adjacent  free  edges. 

A.  B.  C. 


A.  Glottis  in 
Repose. 


Fig.  XIII. 

B.  Gi-OTTis  IN  Deep 
Inspiration. 


C.  Glottis  in  'ihf. 
Production  of  Tone. 


1,  2.  Vocal  cords.  5.  Elastic  band. 

3,  4.  Section  of  the  arytenoid  cartilages.     6,  7.  Processus  musculares  of  arytenoids. 
8,  9.  Processus  vocales  of  arytenoids. 

For  purposes  of  phonation  the  vocal  cords  require  to  be 
accurately  adjusted  to  allow  of  the  production  of  vibration,  and 
this  is  effected  in  part  by  the  muscles  which  approximate  the  cords 
and  render  them  parallel,  and  partly  by  other  muscles,  which, 
by  altering  the  relative  position  of  the  cartilages,  cause  the  cords 
to  become  more  or  less  tense.  The  muscles  concerned  in  approxi- 
mating the  vocal  cords  are  the  crico-arytenoides  laterales  (Fig.  IV., 
5,  7),  which,  by  pulling  the  external  processes  (the  processus  mus- 
culares, Fig.  III.,  4)  of  the  arytenoids  forwards,  rotate  the  interior 
processes  to  which  the  vocal  cords  are  attached  (the  processus 
vocales,  Fig.  III.,  3)  inward,  and  consequently  bring  them  nearer 
to  one  another.  By  the  contraction  of  the  muscle  which 
stretches  from  the  back  of  one  arytenoid  cartilage  to  the  other — ■ 
the  arytenoideus  (Fig.  XII.,  8) — the  cords  are  rendered  parallel. 


ANATOMY  AND  PHYSIOLOGY. 


They  are  rendered  tense  by  the  action  of  the  crico-thyroid 
muscles  (Fig.  XL,  i,  2,  3)  which  tilt  the  thyroid  cartilage  forwards, 
upon  the  cricoid,  thus  elongating  the  cords  and  putting  them  on 
the  stretch  ;  this  tension  can  be  increased  by  the  compression  of 
the  thyro-arytenoidei  muscles  (Fig.  IV.,  i,  2,  3,  4),  which  muscles 
also  tend  to  bring  the  free  borders  of  the  cords  into  more  perfect 
apposition.  When  so  adjusted  the  impact  of  the  expired  air 
against  the  cords  sets  them  in  vibration,  and  these  vibrations  are 
communicated  to  the  column  of  air  passing  between  them,  the 
two  sets  of  vibrations  constituting  vocal  tone;  this  being  modified 
by  the  movements  of  the  lips,  tongue,  soft  palate,  and  teeth, 
becomes  articulate  speech. 

Considered  as  a  musical  instrument,  the  human  larynx  is  far 
too  delicate  and  complicated  a  structure  to  admit  of  adequate 
comparison  with  any  known  musical  instrument.  The  subject  of 
pitch  requires  more  space  than  can  here  be  given  to  its  considera- 
tion. (See  Chap.  IV.)  It  is  not  only  dependent  on  the  tension, 
length,  and  thickness  of  the  vocal  cords,  but  in  a  measure  also 
upon  the  variations  in  length  of  the  tube  itself  from  the  cricoid 
cartilage  upwards.  It  is  doubtful  whether  the  trachea  plays  any 
important  part  in  this  respect,  though  it  has  been  suggested  that 
in  accordance  with  a  general  law,  '  the  calibre  and  length  of  the 
wind-pipe  is  less  in  short  people  than  in  tall,  and,  therefore,  that 
persons  with  high  voices  are  generally  short  in  stature.  V^here 
the  singer  is  tall,  with  tenor  or  soprano  range,  it  has  been  thought 
that  the  wind-pipe  branches  off  very  high  up,  thus  lessening  the 
length  of  the  tube,  and  that  the  wind-pipe  and  larynx  are  dis- 
proportionate to  the  stature  ;  the  opposite  condition  obtaining 
where  persons  of  short  stature  have  low  voices.' 

The  ventricular  bands,  or,  as  they  were  formerly  termed,  the 
'  false  vocal  cords  '  (Fig.  VI.,  7,  8),  have  no  share  whatever  in  the 
initial  production  of  tone  ;  but  may  act  in  absence  of  the  true 
vocal  cords.  They  also  approach  during  '  holding  the  breath,' 
in  '  bearing  down  '  efforts,  and  at  the  commencement  of  the  act 
of  coughing. 

The  function  of  the  ventricles  of  Morgagni  (Fig.  VI.,  5,  6,  7,  8) 
is  probably  to  ensure  greater  freedom  of  motion  to  the  vocal 
cords,  and  by  means  of  the  numerous  glands  contained  in  their 
walls  to  moisten  the  mucous  membrane  of  the  cords,  a  moist 
condition  being  apparently  indispensable  to  normal  voice  produc- 
tion ;  the  duty  of  the  large  mass  of  lymphoid  tissue  lining  the 
ventricle  in  the  manufacture  and  out-pouring  of  scavenging  leuco- 
cytes has  been  previously  alluded  to. 


26 


DISEASES  OF  THE  THROAT  AND  NOSE. 


THE  PALATE  AND  PHARYNX. 

It  is  very  usual,  in  describing  the  appearance  of  the  pharynx, 
to  include  also  the  appearance  of  the  soft  palate,  with  its  pen- 
dulous process,  the  uvula,  and  the  tonsils,  situated  one  on  each 
side  of  the  arch  between  the  anterior  and   posterior  pillars. 

— ^ 


Cephalo- 


or  Naso-phaiMi' 


Hyo-  or 
Oro- pharynx 


Laryngo- 
pharynx. 


I, 


Fig.  XIV. — The  Muscles  of  the  Soft  Palate  and  Fharyn.^. 
(  77/t'  Pharynx  laid  open  from  behind:  Modified  from  Gray.) 

7.  Uvula. 


Levatores  palati,  the  left  being  cut 
short  near  to  its  origin. 

2,  2.  Tensores  palati,  the  left  showing  its 

reflected  tendon  and  relation  to 
the  haniular  process  [a). 

3,  3.  Palato-giossi  (anterior  pillars  of  the 

fauces). 

4,  4.  Palato-pharyngei  (posterior  pillars 

of  the  fauces). 

5,  5.  Tonsils. 

0.  Azygos  uvulce. 


8,  8.  Eustachian  tubes. 

9,  9.  Inferior     constrictors  (laryngo- 

pharyngei). 

10,  10.  Middle  constrictors  (hyo- or  oro- 

pharyngei). 

11,  II.  Superior constrictors(cephalo-or 

naso-pharyngei). 

12,  12.  Epiglottis  and  larynx,  not  laid 

open. 


There  can  be  no  objection  to  such  a  plan,  but,  on  the  contrary, 
there  is  much  to  be  advanced  in  its  favour,  if  it  be  remem- 
bered that  the  pharynx  commences  much  higher  up,  and  extends 
considerably  further  in  a  downward  direction,  than  is  seen  on 
mere  ocular  inspection  of  the  open  mouth — a  fact  not  unfre- 
quently  forgotten  by  young  laryngoscopists. 

The  Palate  forms  the  roof  of  the  mouth,  and  may  be  described 


THE  PALATE  AND  PHARYNX. 


27 


as  consisting  of  an  anterior  part,  hard  palate,  and  a  posterior  part, 
the  soft  palate. 

The  Hard  Palate  is  limited  by  the  alveolar  processes  in  front 
and  at  the  sides  ;  behind  it  is  continuous  with  the  soft  palate. 
The  mucous  membrane  is  here  closely  united  with  the  periosteum, 
forming  together  a  tough  resisting  membrane.  There  is  a  median 
ridge  which  terminates  in  front  in  a  small  papilla,  which  corre- 
sponds to  the  orifice  of  the  anterior  palatine  fossa.  The  mucous 
membrane  on  either  side  is  corrugated,  and  is  covered  with 
squamous  epithelium.  It  contains  numerous  glands,  which  lie 
between  the  mucous  membrane  and  the  surface  of  the  bone. 

The  Soft  Palate  (velum  pendulum  palati — Fig.  XIV.)  is  a  mem- 
branous curtain  attached  to  the  posterior  border  of  the  hard 
palate,  and  separating  to  some  extent  the  cavities  of  the  mouth 
and  pharynx.  Laterally  it  blends  with  the  pharynx ;  but  its 
lower  border  is  free,  and  of  the  outline  indicated  in  Fig.  XXX.  Its 
thickness  is  made  up  of  consecutive  layers  of  muscular  fibres  and 
aponeuroses,  together  with  vessels,  nerves,  acinous  glands,  and 
lymphoid  follicles  (palatal  tonsil)  ;  its  mucous  covering  is  con- 
tinuous with  that  of  the  mouth,  and  is  reflected  back  to  its 
posterior  surface.  It  is  continued  from  the  hard  palate,  and,  like 
it,  is  marked  with  a  median  line  or  raphe,  indicating  its  original 
separation  into  two  portions ;  a  separation  which  sometimes 
persists  as  a  deformity,  to  the  great  detriment  of  the  power  of 
articulation,  swallowing,  etc.,  of  the  individual  so  afflicted. 

The  muscles  of  the  palate  consist  of  five  symmetrical  pairs — 
viz.:  the  levatores  palati  (Fig.  XIV.,  i,  i),  and  the  tensorcc  palati  vel 
dilator  tiibcB  (Fig.  XIV.,  2,  2);  the  palato-glossi,  acting  also  in  pairs 
as  constrictors  of  the  fauces,  and  constituting  their  anterior  pillars 
(Fig.  XIV.,  3,  3)  ;  the  palato-pharyngei  (Fig.  XIV.,  4,  4),  forming, 
in  like  manner,  the  posterior  pillars — between  these  two  muscles 
lie  the  faucial  tonsils  (Figs.  XIV.  and  XV.,  5,  5);  lastly,  the 
azygos  uvidce  (Fig.  XIV.,  6),  which  is  not  a  single  muscle,  as  once 
supposed,  but  a  pair  of  narrow,  cylinder-like  bundles  of  muscles 
placed  side  by  side  in  the  median  line  of  the  soft  palate,  and, 
together  with  connective  and  glandular  tissue,  forming  the 
pendulous  portion  known  as  the  iivtda  (Fig.  XIV.,  7,  etc.). 

The  palatal  muscles  are  concerned  not  only  in  the  act  of  deglu- 
tition, but  also  in  a  greater  or  less  degree  in  vocalization.  The 
importance  of  the  tensor  and  levator  muscles  in  relation  to  the 
opening  of  the  Eustachian  tube,  and  consequently  to  the  auditory 
functions,  cannot  here  be  more  than  alluded  to.  (See  Chap. 
XXVIII.) 

The  utility  of  the  Uvula   has   been   the  subject  of  much 


28 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Speculation.  It  is  without  doubt  of  great  service,  together 
with  the  epiglottis  and  rest  of  the  palate,  in  cutting  off  the  oral 
cavity  from  the  true  respiratory  channel  in  normal  breathing. 
Probably  it  also  acts  as  a  drip-stone,  conducting  the  nasal  secre- 
tions to  the  glosso-epiglottic  fossae,  whence  they  are  directed  by 
the  epiglottis  into  the  pyriform  fossae  as  pointed  out  first  by 
Dobell,  and  more  recently  alluded  to  by  Spicer.  When  relaxed 
abnormally,  the  nares  are  imperfectly  closed  in  the  acts  of  both 
swallowing  and  tone-production,  and  there  is  a  general  paresis  of 
the  palatal  muscles. 

The  Tonsils,  or  amygdalae  (Fig.  XIV.,  5,  5),  are  two  masses  of 
a  peculiarly  composed  lymphoid  tissue,  somewhat  resembling 
almonds  in  shape.  They  are  situated,  one  on  each  side,  in  the 
triangular  depressions  formed  by  the  anterior  and  posterior  pillars 
of  the  fauces,  at  a  point  corresponding  to  the  angle  of  the  jaw. 
Their  normal  size  is  about  three-fourths  of  an  inch  by  half  an 
inch,  the  longest  diameter  being  in  the  vertical  direction.  In 
health  they  should  not  extend  beyond  the  level  of  the  pillars  of 
the  fauces,  though  it  is  not  unusual  to  see  them  transgress  these 
normal  limits  without  producing  any  pathological  symptoms. 
They  may  also  be  much  below^  the  average  size,  with  equally 
negative  results  on  the  health.  The  surface  of  the  tonsil  is  per- 
forated by  a  varying  number  of  slit-like  and  circular  depressions, 
the  common  orifices  of  the  system  of  cavities  which  it  contains. 
Ranged  around  the  walls  of  these  crypts  are  a  number  of  spherical 
or  oral  lymphoid  follicles  or  sacs  embedded  in  the  lymphoid 
parenchyma  of  the  gland.  If  the  tonsil  of  the  rabbit,  with  its  single 
crypt,  be  considered  as  a  lingual  follicular  gland  we  have  in  man  a 
multiplication  of  this  to  the  number  of  from  eight  to  eighteen. 
Externally  they  are  in  relation  with  the  superior  constrictor 
muscle  of  the  pharynx,  outside  which  are  the  internal  and  external 
carotid  and  the  ascending  palatine  arteries,  the  internal  jugular 
vein,  and  the  eighth  and  ninth  nerves.  Below  and  behmd  the 
tonsil  is  sometimes  found  a  small  nodule,  known  as  the  sub- 
pharyngeal  cartilage,  representing  the  remains  of  the  third  post- 
oral  arch.    (See  also  Chap.  XI.) 

The  Pharynx  (Fig.  XV.),  as  generally  considered  in  surgical 
practice,  is  that  portion  of  the  alimentary  canal  which  is  seen  at 
the  back  of  the  mouth.  It  really  extends  from  the  under  surface 
of  the  basilar  process  of  the  occipital  bone  above,  to  a  point 
opposite  the  sixth  cervical  vertebra,  and  on  a  level  with  the 
cricoid  cartilage  below,  where  it  becomes  continuous  with  the 
oesophagus. 


THE  PALATE  AND  PHARYNX. 


29 


The  pharynx  may  be  described  as  a  musculo-fibrous  funnel  of 
from  four  to  five  inches  in  length,  and  capable  of  a  considerable 
amount  of  expansion  and  contraction.  This  funnel  is  widest 
above,  and  is  continued  upward  by  a  dome-like  roof  arching  from 
behind  forward.  The  front  part  of  the  dome  is  imperfect.  A 
good  comparison  is  that  with  a  carriage-hood  having  the  front 
window  drawn  half-way  down.    Speaking  exactly,  its  greatest 


Frc;.  XV.— wSectional  View  of  the  Pharvnx. 

1.  Left  Eustachian  tube.  6,  6.  Upper  and  lower  boundary  of 

2.  Fossa  of  Rose  nmiiller.  larynx  (epiglottis  and  cricoid 

3.  I'alate  and  uvula.  cartilage). 

4.  Tongue.  7.  Cavity  of  nares. 

5.  Left  tonsil.  8.  Cavity  of  mouth. 

breadth  is  opposite  the  cornua  of  the  hyoid  bone ;  its  narrowest 
point  at  its  termination  in  the  oesophagus,  which  commences  on 
a  level  with  the  cricoid  cartilage.  It  is  freely  movable  in  every 
direction,  and  is  in  relation  posteriorly  with  the  cervical  portion  of 
the  spinal  column  as  far  as  the  sixth  vertebra  and  its  covering  ; 
laterally,  with  the  common  and  internal  carotid  arteries,  the  in- 
ternal jugular  veins,  the  vagus,  glosso-pharyngeal,  and  hypoglossal 


DISEASES  OF  THE  THROAT  AND  NOSE. 


nerves.  Anteriorly,  its  line  is  broken,  first,  by  communication  at 
its  upper  extremity  with  the  posterior  nares  (naso-pharynx)  ; 
secondly,  with  the  back  part  of  the  mouth  (oro-pharynx)  ;  and 
thirdly,  with  the  larynx  (laryngo-pharynx),  from  which  it  is  sepa- 
rated by  the  epiglottis  (see  Figs.  XIV.,  XV.,  and  XVI.).  Failure 
of  the  soft  palate  and  fauces  to  shut  off  the  naso-pharyngeal 


Naso- 
pharynx. 


Oi'0-|)har}'Mx 


Laryngo- 
phary  n.\. 


Fto  X^*t.__Sii)f.  Virw  of  ^Tuscles  ok  Pharynx  (after  Gray). 


1.  vStylo-phaiyngeus. 

2.  Styloid  process. 

3.  Upper  jaw. 

4  I'terygo-niaxillary  ligament. 

5.  Lower  jaw. 

6.  Hyoid  bone. 

7.  Thyroid  cartilage. 

8.  Cricoid  cartilage. 


9.  Left   inferior  constrictor  (laryng  )- 
]iharyngeus). 

10.  Left  middle  constrictor  (hyo-  or  oro- 

pharyngeus). 

1 1.  Left  superior  constrictor  (cephalo-  or 

n  aro- phary  ngeus). 

12.  Trachea. 

13.  CEsophagus. 


portion,  or  of  the  epiglottis  to  protect  the  larynx,  ni  the  act  of 
swallowing,  leads  respectively  to  regurgitation  of  food  through  the 
nose,  or  its  passage  into  the  larynx.  Imperfect  closure  of  the  naso- 
pharyngeal space  is  the  cause  of  nasal  tone.  Hypertrophy  of  normal 
lissues,  or  fresh  formations  (enlargements  of  the  pharyngeal  tonsil 
or  adenoid  growths,  polypi,  etc.),  causing  obstruction  of  that 


THE  PALATE  AND  PHARYNX. 


3> 


region,  lead  not  only  to  impediment  to  healthy  respiration  through 
the  nostrils,  the  natural  respiratory  passages,  but  also  to  defective 
nasal  resonance — a  very  different  thing  from  nasal  tone,  though 
the  two  terms  are  often  wrongly  used  as  interchangeable  and 
similai.  Such  obstruction  of  the  naso-pharynx  is  also  provocative 
of  deafness ;  for  it  is  in  the  nasal  portion  of  the  pharynx  that 
communication  takes  place,  by  means  of  the  Eustachian  tube 
(Fig.  XIV.,  8,  8  ;  and  Fig.  XV.,  i),  with  the  middle  ear. 

The  pharynx  has  a  stong  fibrous  investment — the  pharyngeal 
aponeurosis — and  a  mucous  lining  continuous  with  that  of  the 
mouth,  nares,  larynx,  and  Eustachian  tubes.  It  is  covered  by 
columnar  ciliated  epithelium  as  low  down  as  the  level  of  the  floor 
of  the  nares,  below  which  point  the  epithelium  is  squamous.  It 
is  rich  in  glandular  structure  of  the  acinous  and  lymphoid  kinds  ; 
the  former  generally  disseminated,  while  the  latter  are  found 
principally  at  the  upper  portion  (pharyngeal  tonsil)  and  around 
the  orifices  of  the  Eustachian  tubes.    (See  Chap.  XXVI.) 

The  duties  of  the  pharynx  in  relation  to  free  nasal  respiration, 
tone-production,  and  hearing,  may,  notwithstanding  their  import- 
ance, be  after  all  considered  secondary  to  its  main  function — that 
of  carrying  the  food,  after  mastication,  from  the  mouth  to  the 
oesophagus.  This  purpose  is  effected  b}'^  special  muscles,  the 
principal  of  which  are  the  stylo-pharyngei  (Fig.  XVI.,  i),  the  office 
of  which  is  to  lift  up  the  pharynx  for  the  reception  of  the  bolus 
from  the  mouth  ;  and  the  pharyngeal  constrictors  (Figs.  XIV.  and 
XVI.,  9,  10,  11),  three  in  number. 

The  first  constrictor  exposed,  and  the  thickest,  is  the  inferior  (9), 
which  arises  from  the  sides  of  the  cricoid  and  thyroid,  and  spreads 
backwards  and  inwards.  The  middle  (10),  which  is  smaller  than  the 
preceding,  is  fan-shaped,  and  arises  from  the  hyoid  bone  and  stylo- 
hyoid ligament.  The  superior  (11),  which  is  still  thinner,  and  is 
square  in  shape,  has  a  vvide  origin  from  the  sphenoid  and  palate 
bones,  and  from  tendinous  and  ligamentous  tissues  in  the  neigh- 
bourhood. They  are  all  inserted  posteriorly  in  the  fibrous 
aponeurosis  of  the  pharynx,  meeting  their  fellows  of  the  opposite 
side,  the  superior  having  also  an  extension  of  attachment  to  the 
basilar  process.  The  position  of  the  pharyngeal  muscles  is  indi- 
cated in  the  wood  engravings  (Figs,  XIV.  and  XVT.). 

^''Henle  calls  ihese  three  constrictors,  inferior,  middle,  and 
superior,  the  laryngo-pharyngeiis,  hyo-pharyngeus,  and  ccphalo- 
pharyngeiis,  from  their  respective  relations  to  the  larynx,  the 
hyoid  bone,  and  the  bones  of  the  head.  It  would  be  simpler, 
considering  that  their  borders  constitute  the  boundaries  ot  the 


32 


DISEASES  OF  THE  THROAT  AND  NOSE. 


three  portions  of  the  pharynx  to  which  allusion  has  been  made^ 
to  call  them  laryngo-,  oro-y  and  naso-pliaryngei. 

The  glandular  structures  of  the  pharynx  are  of  two  kinds,  viz.,  the 
tubular  or  acinous — mucus-secreting — glands,  and  the  lymphoid  or 
tonsillar — lymph-secreting— glands.  The  acinous  glands  are  found 
principally  on  the  posterior  and  lateral  surface  of  the  pharynx,  and 
on  the  posterior  region  of  the  soft  palate.  The  lymphoid  glandular 
structures  include  the  faucial,  pharyngeal,  lingual,  and  Eustachian 
tubal  tonsils,  together  with  the  lymphoid  masses  of  the  soft  palate 
(palatal  tonsil)  and  the  scattered  follicles  of  the  posterior  wall  of 
the  oro-pharynx  (the  discrete  tonsil).  There  are  also  aggregated 
masses  of  lymphoid  tissue  situated  along  the  salpingo-pharyngeal 
bands  behind  the  posterior  pillars  of  the  pharynx,  which,  w^hen 
enlarged,  give  rise  to  the  condition  known  as  pharyngitis  hypcr- 
trophica  lateralis. 

Recently  it  has  been  truly  said  that  the  understanding  of  the 
lymphoid  (tonsillar)  tissues  of  the  pharynx  is  the  key  to  the 
rational  treatment  of  sore  throat. 

To  terminate  properly  the  description  of  the  pharynx  we  must 
return  to  its  extension  downwards,  viz.,  to — 

The  CEsophagus  (Fig.  XVI.,  13),  which  connects  the  pharynx 
with  the  stomach.  Commencing  at  the  lower  border  of  the 
cricoid  cartilage,  opposite  the  sixth  cervical  vertebra,  it  extends 
downwards  behind  the  trachea  with  a  slight  deviation  to  the  left 
as  far  as  the  root  of  the  neck,  and  again  in  the  same  direction  as 
it  passes  through  the  chest,  piercing  the  diaphragm  opposite  the 
ninth  dorsal  vertebra,  and  terminating  in  the  stomach.  It  also 
curves  antero-posteriorly  in  the  plane  of  the  spinal  column.  Its 
length  is  nine  to  ten  inches,  and  its  diameter  about  three-quarters 
of  an  inch.  At  three  points,  according  to  -'^Mouton — viz.,  (i)  at 
its  commencement,  (2)  three  inches  lower,  and  (3)  as  it  enters  the 
diaphragm — the  diameter  is  lessened,  and  is  not  at  these  situa- 
tions more  than  half  an  inch,  ^igappey's  statements  on  this  head 
are  more  generally  accepted — namely,  that  the  calibre  of  the 
gullet  gradually  diminishes  from  its  upper  commencement  till  the 
level  of  the  fourth  dorsal  vertebra — about  the  half  of  its  length — 
whence  it  again  as  gradually  increases  to  its  termination  at  the 
stomach.  It  is  therefore  composed  of  two  truncated  cones  united 
at  their  apices.  It  is  composed  mostly  of  layers  of  muscular  fibre, 
striated  above,  non-striated  below,  and  is  lined  by  mucous  mem- 
brane, covered  with  stratified  epithelium.  The  sub-mucous  coat 
is  well  marked,  and  contains,  in  addition  to  vessels  and  nerves, 
numerous  elastic  fibres. 


THE  NOSE. 


33 


THE  NOSE. 

It  bein^  proposed  to  include  discussion  of  the  condition  of  the 
nose  in  health  and  disease  in  this  volume,  it  is  desirable  to  remind 
the  readers  of  some  of  its  salient  anatomical  features.  The 
organ  consists  essentially  of  two  parts — an  external,  the  nose 
proper,  with  which  we  need  not  occupy  ourselves  beyond  saying 
that  it  is  built  up  of  cartilage  and  bone,  lined  interiorly  by  mucous 
membrane,  and  is  divided  by  a  median  partition  or  septum  into 


Fig,  XVI r. — Anterior  Sf.ctiox  of  the  Nostrils  (after  Luschka). 


r.  Septum  of  the  iiares  at  position  of  tubercle,  9. 

2.  Middle  turbinated  body,  10. 

3.  Inferior  turbinated  body.  1 1. 

4.  Superior  turbinated  body.  12. 

5.  Superior  meatus.  13. 

6.  Middle  meatus.  14. 

7.  Inferior  meatus.  15. 

8.  Respiratory  portion  of  the  nares.  16.  Cavity  of  orbit. 


Olfactory  portion. 
Floor  of  the  nares. 
Cavity  of  right  antrum. 
Opening  from  antrum  to  nostril. 
Ethmoid  cells. 
Roof  of  the  nasal  fossze. 
Floor  of  the  nasal  fossae. 


tv/o  separate  orifices,  the  nostrils  ;  and  the  internal,  comprising 
the  nasal  fossae.  These  fossse,  which  are  irregularly  quadrilateral, 
or  perhaps,  more  correctly,  wedge-like  in  shape,  are  of  consider- 
able size,  and  open  into  the  pharynx  behind,  through  the  pos- 
terior nares.  The  superficial  area  of  each  fossa  is  increased  by 
the  presence  of  the  turbinated  bones  (Figs.  XVII.  and  XVIII., 
2,  3,  and  4),  three  in  number,  which  grow  from  its  outer  walls, 
and  the  posterior  extremities  of  the  two  lower  of  which  may  be 
seen  from  the  pharynx  by  means  of  the  rhinoscopic  mirror. 

3 


34 


DISEASES  OF  THE  THROAT  AND  NOSE. 


These  turbinated  bones,  which,  with  their  investment  of  erec- 
tile tissue  and  mucous  membrane,  are  known  as  the  turbinated 
bodies,  divide  each  nostril  into  three  choanse  or  supplementary  pas- 
sages—called respectively  the  superior,  middle  and  inferior  meatus 
(Fig.  XVII.,  5,  6,  and  7),  the  latter  constituting  the  floor  of  the 
nostril.  The  whole  of  the  cavity  is  lined  by  the  pituitary  mucous 
membrane,  everywhere  firmly  adherent  to  the  subjacent  perios- 
teum, and  covered  in  the  lower  or  respiratory  portion  of  the 


Fig.  XVIII. — Vertical  Section  of  Head,  showing  Cavity  of  Nose 
[Frotti  Army  Medical  Museum,  Washington,  Section  4,  No.  2352.) 

1.  Nasal  vestibule. 

2.  Middle  turbinated  body. 


3.  Inferior  turbinated  body. 

4.  Superior  turbinated  body. 

5.  Superior  meatus. 

6.  Middle  meatus. 

7.  Inferior  meatus,  and  floor  of 

nostril. 


8.  Position  of  opening  into  antrum 
behind  middle  turbinal. 

9.  Orifice  of  Eustachian  tulje. 

10.  Fossa  of  Rosemiiller. 

1 1.  Frontal  sinus. 

12.  Sphenoidal  cells. 

13.  Posterior  limit  of  nares. 

14.  Uvula,  and  soft  palate. 


cavity  with  columnar  ciliated  epithelium  ;  while  in  the  region 
corresponding  to  the  distribution  of  the  olfactory  nerve  the  ciha 
are  absent,  and  there  is  a  peculiar  and  special  arrangement  of 
nerve  termini  for  the  purpose  of  olfaction.  Everywhere  there 
is  an  abundant  supply  of  muciparous  and  serous  glands,  secreting 
the  viscid,  tenacious  mucus,  whence  the  expression  *  pituitary*  is 


THE  NOSE. 


.•55 


derived.  The  regional  anatomy  and  relations  of  these  parts  will 
be  further  considered  in  the  description  of  the  rhinoscopic  image. 
Their  anatomical  aspects  will  also  be  better  appreciated  by 
reference  to  a  vertical  section  of  the  nasal  cavity  in  Fig.  XVIII. 

The  peculiar  arrangement  of  the  turbinated  bones  and  the 
thickness  of  the  mucous  membrane  narrow  the  passages  left  for 
the  transmission  of  air,  so  that  not  only  are  solid  particles  likely 
to  be  arrested  by  the  moist,  sticky  walls,  but  provision  is  thus 
made  for  warming  and  moistening  the  air  prior  to  its  entrance 
into  the  lungs.    (For  further  details  see  Chap.  XXIV.,  p.  531.) 

The  nasal  cavities  communicate  with  the  ethmoidal  (Fig. 
XVII.,  13),  frontal  and  sphenoidal  sinuses,  and  the  antrum  of 
Highmore  (Fig.  XVIII.,  11,  12,  and  8),  all  of  which  are  lined  by 
a  prolongation  of  the  nasal  mucous  membrane,  and  together  con- 
stitute what  are  known  as  the  accessory  cavities  of  the  nose. 

The  nose  is  generally  described  as  the  organ  of  the  sense  of 
smell,  but  it  must  not  be  forgotten  that  it  has  an  equally  im- 
portant function  to  discharge  in  relation  to  respiration.  In 
fact,  of  its  three  passages,  two  are  devoted  to  respiration,  and 
only  one  to  the  olfactory  apparatus.  It  is  also  to  be  noted  that 
on  the  condition  of  the  nasal  cavity  depends  largely  the  resonance 
and  tone-quality  of  the  voice.  In  connection  with  the  function 
of  the  nostrils  as  part  of  the  respiratory  tract,  the  peculiar  struc- 
ture of  some  portions  of  the  mucous  membrane  is  of  import- 
ance. That  portion  which  covers  the  lower  and  anterior  borders 
of  the  middle  and  inferior  turbinated  bones  is  peculiarly  vascular, 
and  constitutes  a  typically  erectile  structure,  the  physiological 
purpose  of  which  is  doubtless  to  catch  obnoxious  particles  that 
would  otherwise  enter  the  air-passages.  Turgescence  of  this 
erectile  tissue  in  catarrhal  inflammation  leads  to  the  obstruction 
so  characteristic  of  the  complaint.  Irritation  of  these  sites  more- 
over, according  to  ^^John  N.  Mackenzie,  of  Baltimore,  who  has 
made  valuable  contributions  on  questions  of  nasal  pathology, 
causes  reflex  attacks  of  cough  ;  and  he  has  noticed  cases  where 
troublesome  and  long^continued  cough,  unaccounted  for  else- 
where, has  been  cured  by  emolhent  applications  to  these  spots. 
The  same  observer  has  also  drawn  attention  to  the  fact  that  there 
is  a  very  distinct  and  close  relation,  anatomical  and  functional, 
between  this  erectile  structure  and  the  sexual  apparatus,  and  he 
has  afforded  several  evidences,  both  physiological  and  patholo- 
gical, in  support  of  his  views  (see  Chap.  XXIV.). 

The  Mucous  Membrane  may  be  divided  into  two  chief  regions — 
the  respiratory  and  the  olfactory.    The  former,  however,  must 

3—2 


DISEASES  OF  THE  THROAT  AND  NOSE 


be  again  divided  into  the  vestibular  or  epidermal,  and  the 
Schneiderian. 

The  Vestibular  or  cartilaginous  portion  is  epiblastic  in  origin  and 
therefore  lined  by  a  modification  of  the  skin,  presenting  numerous 
hairs  (particularly  in  the  male  sex),  sebaceous  glands,  and  a  few 
papilla:;.  The  whole  is  covered  by  stratified  epithelium  and  is  closely 
attached  to  the  subjacent  cartilage. 

The  Respiratory  or  hypo-blastic  portion  is  that  region  which 
is  situated  behind  the  cartilaginous  area,  and  is  bounded  superiorly 
by  the  lower  border  of  the  middle  turbinal.  It  is  in  marked  con- 
trast, both  in  colour  and  width  with  that  of  the  olfactory  region 
above  it.  The  investing  epithelium  is  entirely  of  the  columnar  ciliated 
variety,  with  small  intermediate  and  goblet  cells,  surmounting  a 
delicate  hyaline  basement  membrane.  Beneath  this  are  scattered 
albuminous  and  mucous  glands  (compound  acino-tubular),  numer- 
ous but  small  on  the  septum,  fewer  but  longer  on  the  (inferior) 
turbinal :  these  are  embedded  in  a  mass  of  erectile  tissue,  lym- 
phoid tissue,  and  visceral  muscle-fibres. 

The  Olfactory  area,  which  practically  includes  all  that  portion 
above  the  lower  border  of  the  middle  turbinal,  has  a  somewhat 
yellowish  appearance,  due  to  the  presence  of  pigment,  so  character- 
istic of  the  terminals  of  the  nerves  of  special  sense.  Occasionally 
small  islands  of  ciliated  cells  appear,  but  for  the  most  part  this 
surface  is  occupied  by  the  plain  columnar  cells  of  Schultze, 
which,  along  with  two  other  varieties,  to  be  immediately  de- 
scribed, constitute  the  terminals  of  the  olfactory  nerve.  These 
long  columnar  bodies  are  striated  at  their  free  surface,  but, 
deeply,  they  are  branched  and  lost  in  the  subjacent  connective 
tissue,  and  do  not  seem  to  form  any  direct  connection  with 
the  olfactory  nerve.  They  contain  pigment  and  large  nuclei. 
A  second  kind  of  cell  is  sometimes  spoken  of  as  the  olfactory  cell, 
from  its  root  being  traced  into  communication  with  the  olfactory 
nerve  ;  it  is  long,  thin,  and  tapering,  has  a  well-marked  oval 
nucleus,  and  reaches  the  surface  between  the  large  columnar 
bodies  as  a  delicate  fibril.  The  third  form  of  cell  is  flattened  and 
arranged  as  a  species  of  basement  membrane  pierced  by  the  nerves 
and  by  Bowman's  gland  ducts.  The  tapering  cells  are  usually 
considered  the  '  special,'  whilst  the  columnar  are  the  '  supporting' 
cells.  Bowman's  glands,  exclusively  found  in  this  area,  are  simple 
acino-tubular  structures  lined  by  polygonal  granular  cells.  In  the 
respiratory  area  the  glands  are  much  larger  and  coarser  than  Bow- 
man's, and  are  for  the  most  part  albuminous  ;  hence  mucus  must 
be  derived  not  so  much  from  the  dands  as  from  the  surface  rellb. 


THE  NOSE. 


37 


Surrounding  the  non-medullated  olfactory  fibril  are  perineural 
lymph  spaces,  which  are  directly  continuous  with  the  sub-dural 
and  sub-arachnoid  lymph  spaces. 

On  the  nasal  septum,  just  above  the  opening  of  Stenson's 
canal,  is  seen  a  slight  oblique  thickening,  which  represents  the 
remainder  of  the  organ  of  Jacobson.  It  consists  of  a  small  pouch 
lined  by  ciliated  epithelium,  and  in  the  embryo  receives  a  twig 
from  the  olfactory  nerve.  Just  beneath  this  pouch  is  a  small 
plate,  about  4  mm.  in  length,  known  as  the  Jacobsonian  cartilage; 
it  is  attached  by  fibrous  tissue  to  the  septum. 

Innervation. — The  nasal  branch  of  the  upper  division  of  the 
fifth  supplies  the  upper  and  anterior  part  of  the  septum  and  outer 
wall  of  the  fossae.  Twigs  from  the  anterior  dental  go  to  the 
lower  meatus  and  turbinal.  The  upper  and  posterior  part  of  the 
septum  and  the  superior  turbinal  receive  fibres  from  Meckel's 
ganglion,  whilst  the  naso-palatine  supplies  the  middle  of  the 
septum,  and  the  anterior  palatine  the  middle  and  lower  turbinals. 
Recent  observations  on  the  histology  of  the  olfactory  bulb  and  its 
distribution  have  established  a  strong  likeness  between  it  and  the 
retina. 

The  Eustachian  tube  (Fig.  XIV.,  8  ;  Fig.  XV.,  i  ;  and  Fig. 
XVI II.,  9}  is  a  canal  of  small  calibre,  about  one  line  in  diameter, 
by  means  of  which  a  communication  is  maintained  between  the 
middle  ear  and  the  naso-pharynx,  and  the  pressure  of  air  on  both 
sides  of  the  membrana  tympani  is  thus  equalized.  Its  length  is 
from  one  and  a  half  to  two  inches,  and  it  runs  from  the  pharynx 
upwards,  outwards,  and  backwards.  It  consists  partly  of  bone 
and  partly  of  cartilage  and  fibrous  tissue,  and  is  lined  by  a  con- 
tinuation of  the  mucous  membrane  of  the  pharynx. 

REFERENCES  TO  AUTHORITIES. 


TITLE  OF  WOKK  REFERRED  TO. 


LUSCHKA. 
C.  LUDWIG. 

Elsberg. 

Bland  Sutton. 
Mayo  Collier. 

Carmalt  Jones. 

HOWSE. 
J.  FOULIS. 


j  (Dcr  Kehlkopf  des  Meiischen,  Tubingen, 

;\  1871. 

j  i  Lehrbuch  der  Physiologic  des  Meiischcii, 


New 


'  The  Throat  and  its  Function 
.    York,  p.  31. 

journal  of  Anatomy,  Eondon,  1889. 
!  Journal  of  Laryngology,  June,  1888. 
'  f  Trans.  Intern.  Med.  Cong.,  Warling 
\    ton,  1887. 

Journal  of  A nato/ny,  London,  1889. 
j  British  Med.  Journal,  vol.  i.,  1889 
^-    pp.  103  and  653. 


33 


DISEASES  OF  THE  TffROAT  AND  NOSE. 


PAGE. 

j  NO. 

NAME. 

14 

i 

9 

Howard. 

14 
16 

10 
II 

Bowles. 
Hill. 

18 

12 

INIerkel. 

18 

'  3 

Turner. 

20 

14 

Majendie. 

20 

IS 

Hooper. 

20 

16 

Desvernine. 

22 

17 

Heitler. 

23 

18 

Cheadle. 

31 

19 

Henle. 

32 

20 

MOUTON. 

32 

21 

Sappey. 

35 

22 

John  N.  Mackenzie 
(Baltimore). 

TITLE  OF  WORK  REFERRED  TO. 


{British  Med.  Jotirnai^  pp.  42,  269, 
\    and  563. 

British  Med.  Journal,  pp.  65  and  384. 

Tonsillitis,  etc.,  London,  1889. 
(Aiiatomy  and  Physiology  of  the  Organs 
of  Voice  and  Speech,  pp.  132,  133, 
y    Leipzic,  1857. 

f  Edinburgh  Mcdicaljoiirnal,  February, 
\  i860. 
Mcmoire,  Paris,  1813. 

{Experimental  Researches  on  the  Ten- 
\  sion  of  the  Vocal  Bands,  New  York, 
[  1882. 

\jonr71al  of  Laryngology,  February, 
\  1888. 

(Strieker's  Medizinische  Jahrbiicher^ 
\    vols.  iii.  and  iv. 

Trans.  Roy.  Med.  Chir.  Soc,  1888. 
( HandbucJi  der  Syste/iiatischen  Anato- 
\     mie  des  Menschen,  ii.  Band,  Braun- 
\    schweig,  1866. 

i Dii  Calibre  de  t  CEsophage,  Paris, 
I  1874. 

r  Ti'aite  d'  Anatomic  Descj'iptive,  vol.  iv., 
\    Paris,  1879. 

(American Journal oj Medical  Sciences, 
\   July,  1883. 


For  further  information  see  also  articles  by  Elsberg,  Minute  Anatomy  of  the  Larynx, 
vol.  i. ;  and  Contributions  to  the  Normal  and  Pathological  Histology  of  the  Cartilages  of 
the  Larynx,  vol.  iii.  of  the  Archives  of  Laryngology,  by  Carl  Seller  ;  Researches  in  the 
Minute  Anato??iy  of  the  Larynx,  Normal  and  Pathological,  vols.  i.  and  ii.  of  the  same 
Archives ;  and  for  very  complete  recent  information  on  the  Anatomy  of  the  Nose,  to 
Zuckerkandl's  Normale  und  Pathologische  Anatomic  der  Nascnhole  tmd  ihrcr  Pnezi- 
viatischen  Anhaeiige,  Wien,  1882. 


CHAPTER  II. 


EXAMINATION  OF  THE  THROAT  AND  LARYNX  — THE 
LARYNGOSCOPE. 

It  is  difficult,  by  a  mere  verbal  description,  to  explain  clearly  any 
process  requiring  technical  apparatus  and  skill,  and  one  practical 
lesson  is  of  more  value  than  a  dozen  pages  of  written  directions. 

Our  purpose  being,  however,  to  make  laryngoscopy  intelligible 
to  those  who  are  unable  to  avail  themselves  of  personal  instruction,, 
this  will  probably  be  best  effected  by  enumerating  and  describings 
somewhat  dogmatically,  the  steps  to  be  taken  in  making  a  laryngo- 
scopic  examination.  The  most  probable  causes  of  failure  will 
then  be  pointed  out,  with  directions  how  to  avoid  those  which 
depend  on  the  observer,  and  to  overcome  those  which  are  due  to 
obstacles  pertaining  to  the  patient ;  pursuing  thus  precisely  the 
same  course  as  if  personally  instructing  a  pupil  at  hospital. 

It  is  impossible  to  overestimate  the  value  of  good  illumination 
in  facilitating  the  obtaining  a  clear  and  useful  view  of  the  larynx. 
For  this  reason  the  question  of  the  relative  merits  of  the  different 
sources  of  light  will  be  gone  into  as  thoroughly  as  possible.  In 
the  treacherous  climate  of  England,  and  especially  of  London,  it 
is  almost  essential  to  have  recourse  to  artificial  illumination,  supx- 
light  being  so  rarely  available.  Of  the  various  forms  of  artificial 
Ught,  that  afforded  by  gas  is,  for  constant  use,  on  all  accounts  the 
best,  and  no  lamp  can  be  more  complete  than  the  universal  rack- 
movement  apparatus.  Until  the  last  twelve  years  all  my  work  was 
done  by  aid  of  a  lamp  (Fig.  XIX.),  the  light  of  which  is  in  every 
respect  similar  to  that  of  the  rack-movement  lamp,  but  the 
apparatus  of  which  is  constructed  on  the  principle  of  the  Queen's 
reading-lamps.  This  form  of  lamp  is  not  only  much  less  expensive 
than  the  rack-movement,  but  it  can  be  attached  to  an  ordinary 
gas-burner  by  an  elastic  tube,  and  can  be  adapted  for  ophthalmo- 
scopic examination  or  used  as  an  ordinary  study  light.  The 
illuminating  power  of  an  Argand  burner  in  such  a  lamp  is  given 


40 


DISEASES  OF  THE  THROAT  AND  NOSE. 


as  that  of  ten  candles,  but  this  is  much  diminished  by  the  lens 
and  the  reflector. 

Where  gas  cannot  be  obtained,  any  lamp,  such  as  a  Moderator, 
Queen's,  Paraffin,  or  Duplex,  which  gives  a  bright  steady  light, 


Fig.  XIX.— a  Convenient  Standard  Gas  Lamp,  with  Arga.nd  Uuk.ner,  which 

CAN  BE  ATTACHED  TO  ANY  GaS-JET,  AND  CAN  BE  USED  FOR  VARIOUS  PURPOSES. 

will  answer  the  purpose ;  and  a  practised  laryngoscopist  may 
obtain  a  good  image  even  with  a  candle  in  a  bull's-eye  lantern,  or 
with  a  carriage-lamp.  Several  useful  portable  lamps  are  sold  by 
the  instrument-makers.  Dr.  George  Johnson's  pocket-condenser 
is  invaluable  for  country  practitioners  ;  but  in  the  absence  of  a 


EXAMINATION  OF  THE 


THROAT  AND  LARYNX. 


41 


condensin^^  lens  a  piece  of  white  paper  placed  behind  a  lamp  or 
candle  will  add  considerably  to  the  brilliancy  of  the  light. 

Since  the  first  edition  of  this  work  appeared  in  1878,  I 
succeeded,  after  many  trials,  in  perfecting  a  limelight  now 
known  by  my  name,  although  I  make  no  particular  claim  to 
originality ;  for  the  idea  was  suggested  to  me  by  Mr.  Behnke, 
and  the  first  lamps  were  executed  under  our  joint  direction  by 
Messrs.  Wood,  of  Cheapside.  Various  improvements  in  detail, 
the  result  of  further  experience,  have  since  been  introduced  by 
Messrs.  Coxeter,  who  now  manufacture  the  apparatus  as  used  by 
me.  The  illuminating  power  is  not  only  all  that  can  be  desired, 
but  it  is  at  the  same  time  economical,  and  easy  of  manipulation. 

The  following  is  a  description  of  the  apparatus,  which  appeared 
in  the  Specialist  of  September  ist,  1880,  and  to  it  nothing  need  be 
added  except  that  ten  years'  subsequent  and  daily  experience  has 
amply  confirmed  the  promise  first  held  out  of  its  superiority  over 
all  other  methods  of  oxy-hydrogen  illumination ; 

The  apparatus  consists  essentially  of  the  following  parts  : 

1.  Thfc  source  of  the  light. 

2.  The  rectifying  lenses  for  converting  the  ray  of  light  into  a  parallel  beam. 

3.  The  absorbment  cell,  for  arresting  the  calorific  rays. 

4.  The  principal  chamber  for  containing  the  various  parts. 

5.  The  igniter  and  dissolver,  for  instantaneously  producing  and  extinguishing  the  light. 

The  various  parts  viuU  be  well  understood  by  a  reference  to  the  illustration. 

The  Source  of  Light — This  is  marked  S  in  the  engraving,  and  it  consists  of  the 
most  improved  form  of  oxy-calcium  jet.  Two  gases  are  required  from  this  jet — viz. ,  oxygen 
and  hydrogen  ;  but  these  gases  do  not  mingle,  nor  do  they  come  into  contact  with  each 
other. 

The  hydrogen  is  ignited  like  any  ordinary  gas-jet,  and  the  oxygen  is  then  admitted,  ' 
which,  coming  into  contact  with  the  box  of  the  hydrogen  flame,  instantly  produces  a  jet 
of  enormous  heating  power.    This  jet  flame  impinges  on  the  face  of  a  cylinder  of  lime 
(marked  L)  immediately  in  front  of  the  jet  S.    The  lime  becomes  incandescent,  and  emits 


Fig.  XXII. — The  Lennox  Browne  Limelight  Apparatus. 


an  intense  light.     Two  taps  T  are  provided  for  the  jet,  one  with  a  hole  through  the  fiat 


42 


DISEASES  OF  THE  THROAT  AND  NOSE. 


part  of  the  key— this  is  the  oxygen  tap ;  the  other,  which  is  not  pertorated,  being  ihe 
hydrogen  tap.  By  means  of  these  taps  the  relative  quantities  of  the  two  gases  can  be 
regulated  with  the  greatest  facility. 

The  hydrogen  gas  as  employed  by  me  is  the  ordinary  carburetted  hydrogen  or  street 
gas,  and  is  obtained  from  the  usual  gas-fittings.  The  oxygen  gas  is  used  from  a  bag.  In 
consequence  of  this  arrangement  only  one  gas-bag  is  required  ;  and  thus,  as  well  as 
because  the  gases  only  meet  at  the  actual  point  of  ignition,  an  explosion  is  impossible.  The 
oxygen  gas  requires  the  simplest  apparatus  for  manufacture,  and  can  be  made  by  any 
intelligent  man  after  a  few  minutes'  instruction. 

The  Rectifying  Lenses.— These  (shown  by  the  dotted  lines,  and  marked  R  L)  are 
required  in  order  to  change  the  widely  divergent  rays  emitted  from  the  lime  into  the  form 
of  a  cylinder  of  light,  the  section  of  which  is  about  equal  to  the  area  of  the  frontal  mirror 
used  by  the  laryngoscopist.  These  lenses  do  not  require  any  adjustment ;  they  are  placed 
so  that  the  radiant  spot  of  the  lime-cylinder  is  in  their  principal  focus. 

The  Absorbment  Cell.— This  is  marked  A  C.  It  is  made  of  glass,  with  parallel 
sides,  and  is  held  by  metal  clips  in  front  of  the  rectifying  lenses,  with  a  sufficient  space 
between  them  to  allow  of  a  free  interchange  of  air.  This  cell  is  filled  with  water,  which 
does  not  require  changing  unless  the  apparatus  is  being  used  for  long  periods  without 
intermission.  The  water  may  even  attain  a  considerable  heat  without  increasing  that 
emitted  by  the  light. 

The  usefulness  of  the  absorbment  cell  is  shown  by  placing  a  thermometer  an  inch  or 
two  in  front  of  it,  in  the  centre  of  the  beam  of  light.  Under  these  circumstances  the 
temperature  will  be  seen  to  be  scarcely  raised  at  all  ;  but  if  the  cell  be  removed,  it 
speedily  rises  to  50°  or  60°. 

The  Principal  Chamber. — This  is  marked  P  C,  and  it  consists  of  a  vertical  brass 
cylinder,  having  on  one  side  a  tube  carrying  the  rectifying  lenses,  and  at  its  base  a 
divided  socket  marked  D  S,  by  means  of  which  it  can  be  attached  to  the  arm  of  the 
ordinary  gas-standard  G  S  without  in  any  way  interfering  with  or  deranging  the  same. 
The  limelight  jet  is  also  fixed  in  this  chamber  in  its  right  position,  and  requires  no  further 
adjustment.  It  may  not  be  out  of  place  in  this  connection  to  mention  that  the  limes  now 
used  are  much  lc;s  fragile  and  more  durable  than  was  formerly  the  case.  A  lime  supplied 
with  this  apparatus  will  last  for  several  sittings,  provided  it  be  removed  after  use  and  kept 
dry  in  a  metal  box.  A  simpler  plan  is  to  allow  the  small  pilot-flame  to  remain  burning, 
which  prevents  the  lime  becoming  damp,  and  preserves  a  cylinder  for  a  long  time. 

The  Igniter  and  Dissolver. — This  is  the  only  part  remaining  to  be  described.  It  is 
marked  in  the  illustration  I  T.  The  igniter  is  a  specially  contrived  four-way  tap  through 
which  the  gases  flow  in  order  to  supply  the  jet.  This  tap  is  provided  with  a  lever  handle, 
which  moves  through  a  regulated  arc,  so  that  by  one  movement  the  gases  are  turned  on 
or  off  at  pleasure. 

When  it  is  retiuired  that  the  light  should  be  produced  it  is  only  needed  that  the  lever, 
which  is  placed  close  to  the  hand  of  the  operator,  be  moved,  and  the  full  light  is 
instantaneously  obtained.  The  igniter  is  connected  with  the  jet  by  means  of  flexible 
tubes,  so  that  the  igniter  can  be  fixed  to  the  top  of  the  operating  table,  and  the  jet  can 
be  raised  or  lowered  at  pleasure,  so  as  to  provide  for  all  required  conditions. 

Directions  for  Use.  — See  that  all  the  parts  of  the  apparatus  are  clean  and  free  from 
dust,  and  refill  the  absorbment  cell  with  water.  Put  a  lime-cylinder  on  to  the  lime-holder, 
and  see  that  the  face  of  the  cylinder  comes  all  but  close  to  the  sloping  jet.  Turn  off  the 
taps  at  the^  back  of  the  jet,  and  turn  the  lever  of  the  igniter  to  the  word  '  open.'  See 
lhat  the  proper  weights  are  on  the  bag  containing  the  oxygen  gas  (about  two  half-cwts,), 
and  open  the  tap  of  the  same,  and  also  the  tap  or  taps  that  connect  the  apparatus  with 
the  gas  main. 

When  this  has  all  been  done  the  apparatus  is  ready  to  be  lighted.  The  hydrogen  tap 
at  the  back  of  the  jet  is  to  be  partly  opened,  and  the  gas  ignited  and  the  flame  allowed  to 
play  upon  the  lime  for  a  few  minutes  so  as  to  heat  it  gradually.    The  oxygen  tap  at  the 


EXAMINATION  OF  THE  THROAT  AND  LARYNX. 


43 


back  of  the  jet  should  now  be  gradually  opened  until  the  full  amount  of  light  is  obtaineii ; 
then  a  little  more  hydrogen,  and  then  a  little  more  oxygen  may  be  added,  until  the 
desired  result  is  secured.  T/ie  taps  at  the  back  of  the  jet  will  not  require  any  ?nore 
attention;  the  igniter  performs  all  else  that  is  needed. 

It  will  be  observed  that  there  is  a  screw  passing  through  a  pillar  in  the  plate  of  the 
igniter,  against  which  the  end  of  the  lever  stops.  This  screw  is  required  to  regulate  the 
length  of  the  arc  through  which  the  lever  moves,  and  consequently  the  size  of  the 
permanent  hydrogen  flame.  As  this  screw  is  drawn  back  the  tap  is  more  nearly  turned 
off,  and  the  size  of  the  permanent  flame  is  decreased  ;  whereas  to  the  extent  that  the  end 
of  this  screw  is  pushed  forward  the  size  of  the  permanent  flame  is  increased. 

When  the  apparatus  is  done  with,  the  taps  at  the  back  of  the  jet  should  be  turned  off, 
as  also  the  tap  of  the  bag  and  the  tap  connecting  the  apparatus  with  the  gas  main. 

Any  portion  of  the  apparatus  can  now  be  removed  and  put  away. 

The  advantages  of  the  above  combination  are,  first,  that  it  is  exceedingly  simple,  and, 
being  made  to  fit  on  to  the  ordinary  gas-standard,  does  not  require  any  cumbersome 
arrangement  of  lantern.  If  from  any  cause  it  should  be  desirable,  the  whole  thing  can  be 
unshipped  in  two  minutes,  and  the  gas-light  made  immediately  available. 

It  can  be  used  either  as  a  direct  light  or  with  the  usual  frontal  or  hand-reflector.  This 
is  a  point  of  considerable  importance,  since  in  the  first  place  the  direct  method  ot 
examination — I  speak  more  particularly  of  throats  and  ears — is  inconvenient  to  those 
accustomed  to  the  use  of  the  reflector  ;  in  the  second,  reflected  light  is  infinitely  preferable 
when  it  is  desired  to  follow  even  slight  movements  of  the  patient,  as  is  always  the  case, 
and  especially  when  performing  operations.  Needless  to  say,  however,  that  the  lamp  is 
equally  available  for  direct  light. 

By  means  of  the  absorbment  cell  the  amount  of  heat  is  rendered  less  than  that  of  an 
ordinary  Argand  burner. 

The  igniter  and  dissolver  economise  the  oxygen  by  a  movement  most  simple  and  easy 
to  the  operator. 

The  initial  cost  is  very  small  ;  the  expense  of  the  one  fixed  at  the  Central  Throat  and 
Ear  Hospital,  including  all  connections,  bags,  etc.,  was  only  ;^i5. 

The  cost  of  the  gas,  made  by  heating  chlorate  of  potash  and  peroxide  of  manganese, 
does  not  exceed  is.  3d.  per  bag  of  ten  cubic  feet  of  gas.  If  care  be  taken  to  avoid  waste, 
not  more  than  two  cubic  feet  per  hour  of  oxygen  are  necessary  with  the  constant  use  of 
hospital  practice  ;  in  other  words,  the  cost  of  the  light,  inclusive  of  the  carburetted 
hydrogen,  is  not  more  than  2d.  an  hour. 

This  limelight  was  tested  some  time  since  by  Messrs.  Silber, 
who  estimated  it  as  equal  to  fifty  of  their  lights,  or  1,000  candle- 
power.  Candle-power  is  a  term  of  very  arbitrary  character,  and 
one  often  improperly  applied.  When  a  light  is  focussed  on  to 
any  one  point,  the  illuminating  power  is  probably  but  a  third  or 
fourth  of  what  would  be  the  whole  circle  of  the  flame.  I  am 
certainly  inclined  to  think  the  above  estimate  too  liberal  if  coal 
gas  be  used ;  and  naturally  the  light  will  vary  considerably, 
according  to  the  quality  and  pressure  of  the  gas.  But  if  con- 
densed oxygen  be  used  from  a  metal  cylinder,  the  light  is  nearly 
twice  as  brilliant  as  when  used  from  a  bag  ;  and  the  substitution  of 
pure  hydrogen  for  coal  gas  is  also  attended  with  great  increase  of 
illuminating  power.  In  any  case,  at  its  lowest  figure  it  far 
exceeds  any  ordinary  means  of  illumination,  and  must  commend 


44 


DISEASES  OF  THE  THROAT  AND  NOSE. 


itself  to  specialists.  Until  quite  recently  it  has  been  used  to  the 
exclusion  of  all  others,  both  in  my  private  and  in  my  hospital 
practice.  It  has  also  received  the  approbation  of  many 
American  and  Continental  practitioners,  who  have  adopted  it  in 
their  practice. 

It  has  been  stated  that  the  limelight,  in  spite  of  the  improve- 
ments introduced  by  me,  still  remains  decidedly  more  expensive 
and  cumbersome  than  the  electric  light.  While  not  prepared  to 
admit  that  this  is  the  case,  it  must  be  borne  in  mind  that  the 
illuminating  power,  given  at  from  500  to  1,000  candles,  and  after 
all  allowance  for  greater  distance  from  the  object  illuminated  and 
for  the  use  of  reflectors,  is  fifty  or  a  hundred  times  greater  than 
that  of  the  electric  light  with  its  nominal  lighting  power  of  four, 
and  probable  actual  power  of  two,  candles.  I  speak  of  the  light 
given  by  a  Trouve  lamp  known  as  No.  4,  which  is  the  one 
generally  employed. 

It  is  unfortunate  that  incandescent  lamps  of  the  shape  used  in 
lighting  houses  are  not  fitted  for  laryngoscopic  purposes,  as  the 
picture  of  the  carbon  filament  is  always  visible,  and  shadows  are 
produced  which  make  a  correct  examination  impossible.  More- 
over, since  the  filament  is  irregularly  distributed  over  a  large  area, 
its  rays  cannot  be  brought  into  focus  by  a  lens. 

These  difficulties  have  been  overcome  in  an  excellent  focus- 
lamp  made  by  Messrs.  Schall.  The  filament  is  replaced  by  a 
broad  carbon  ribbon,  which  is  wound  to  a  spiral  in  the  middle  of 
the  lamp.  In  this  way  the  whole  of  the  available  light  is  con- 
centrated into  a  small  space,  and  the  uniform  rays  thus  obtained 
are  further  brought  into  focus  by  means  of  a  bull's-eye.  The 
lamps  can  be  procured  of  any  candle-power,  but  those  most 
commonly  in  use  are  32,  50,  100,  and  250  candles.  Experiments 
have  shown  that  the  light  of  a  loo-candle  lamp  is  about  equal  to 
an  ordinary  hmelight  fed  with  coal-gas  and  oxygen,  while  the  250- 
candle  lamp  is  considerably  stronger.  At  the  same  time,  it  may 
be  noted  that  the  limelight  obtained  from  hydrogen  and  oxygen 
produces  about  1,000  candles. 

The  lamp  itself  is  constructed  very  much  like  that  of  a  lime- 
light, being  fitted  in  a  bracket  movable  in  all  directions.  An 
apparatus,  consisting  of  a  glass  cell  filled  with  water,  absorbs 
the  rays  of  heat,  and  one  side  of  this  coohng  vessel  is  formed 
by  a  second  lens,  by  means  of  which  the  rays  of  light  are  made 
to  converge  on  the  forehead-mirror. 


EXAMINATION  OF  THE  THROAT  AND  LARYNX, 


45 


The  incandescent  lamps  can  be  easily  exchanged,  and  the 
apparatus  has  the  advantage  of  great  convenience  and  illumi- 
nating power,  and  of  making  its  owner  independent  of  the  supply 
of  gas.  The  first  cost  is  about  equal  to  that  of  a  limelight-lamp, 
and  the  consumption  of  electricity  amounts  to  2^d.  an  hour  for  a 
loo-candle  lamp. 

Before  proceeding  to  describe  the  method  of  using  the  laryngo- 
scope, a  brief  account  of  the  instrument  itself  is  necessary. 

Strictly  speaking,  the  laryngoscope  consists  of  but  one  instru- 
ment— namely,  a  small  mirror,  which,  when  placed  at  the  back 
of  the  mouth,  and  illumined  either  by  solar  or  artificial  light, 
reflects  the  image  of  the  cavity  of  the  larynx,  and  of  more  or  less 
of  the  trachea. 

The  majority  of  practitioners  examine  by  the  aid  of  indirect  or 
reflected  light,  and  for  this  purpose  a  second  mirror  is  required. 


Fig.  XXIII.— Laryngeal  Reflector  (Half  Measurements). 


Laryngoscopy,  then,  as  usually  practised  in  this  country,  involves 
the  use  of  two  mirrors — one  to  concentrate  and  reflect  the  illu- 
minating rays  on  to  the  fauces,  and  the  other  to  throw  the  light 
thus  reflected  into  the  larynx,  the  image  of  which  it  in  turn 
reproduces. 

These  two  mirrors  are  called  the  Reflector  and  the  Laryngeal 
Mirror  respectively.  I  propose  simply  to  describe  the  means 
and  method  of  examination  which  I  am  in  the  habit  of  prac- 
tising, without  entering  into  minute  details  as  to  the  differences 
in  practice,  by  no  means  essential,  of  various  laryngoscopists. 

The  Reflector  (Fig.  XXIII.)  is  a  circular  mirror  about  three  and 
a  half  inches  in  diameter,  perforated  with  a  small  hole  in  the  centre, 
and  fixed  by  a  ball-and-socket  joint  to  a  kind  of  spectacle-frame, 
the  lower  rims  of  which  have  been  removed.  This  is  supported 
on  the  bridge  of  the  nose  by  a  plate  of  tolerably  soft  metal,  which 


46 


DISEASES  OF  THE  THROAT  AND  NOSE. 


can  be  adapted  to  the  individual  examiner.  This  instrument, 
first  devised  by  Duplay  and  known  in  England  as  mine,  will  be 
found  much  less  fatiguing  for  long-continued  use  than  that  of 
Semeleder  (also  called  by  English  makers  after  Mackenzie),  which 
clips  the  nose  like  ordinary  spectacles.  The  removal  of  the  lower 
instead  of  the  upper  rim  is  also  a  very  real  advantage,  as  the 
lower  rim  always  comes  in  the  way  of  the  vision.  Practitioners 
who  are  shortsighted  can  easily  have  suitable  glasses  fixed  into 
this  frame.  The  reflector  should  be  slightly  concave  for  use  with 
artificial  light,  but  plane  for  sunlight  examination.  The  com- 
bination of  the  two  in  a  folding  frame,  as  long  used  by  ophthalmo- 
scopists,  can  be  conveniently  carried  in  the  pocket.  The  usual 
focal  distance  is  from  eight  to  fourteen  inches,  and  it  is  important 
that  practitioners  should  obtain  accurate  information  on  this  point 

a 


Fig.  XXiV.— The  L.vrg.ngeal  Mirror. 
a.  The  mirror  (half  measurements). 

d,  c,  d,  represent  exact  size  of  the  reflecting  surface  of  mirrors  of  varying  dimens'cns. 

before  buying  a  reflector,  in  order  that  they  may  adapt  it  to  their 
own  vision,  whether  long  or  short,  and  may  also  know  at  what 
distance  their  head  should  be  from  the  patient,  so  as  to  obtain  a 
proper  disc  of  light. 

The  reflecting  mirror  may  be  worn  either  over  the  forehead  or, 
preferably,  over  the  right  e3'e,  the  central  orifice  being  utilized  for 
visual  purposes  ;  in  the  latter  case  both  eyes  are  protected  from 
the  glare  of  the  light — the  one  directly,  and  the  other  by  the 
shadow  which  the  reflector  casts. 

The  Laryngeal  Mirror  (Fig.  XXIV.)  is  circular  in  shape,  made 
of  glass  silvered  on  the  back,  set  in  a  German-silver  frame,  and 
attached  at  an  angle  of  120°  to  a  slender  shank  of  the  same  metal 
about  three  and  a  half  inches  in  length  :  this  shank  is  further 
fitted  into  an  ebony  or  ivory  handle  four  inches  long.  Quite 


EXAMINATION  OF  THE  THROAT  AND  LARYNX.  t,n 

recently  Coxeter  has  improved  these  mirrors  by  making  the 
frame  and  shank  in  one  piece  of  steel,  nickel-plated. 

The  mirrors  are  about  one-twelfth  of  an  inch  thick,  and  are 
made  in  three  varying  sizes,  the  diameters  being  half  an  inch, 
four-fifths  of  an  inch,  and  one  inch  respectively. 


Fig.  XXV. — Diagram  Illustrating  the  Principle  of  the  Laryngoscope. 

The  principle  on  which  the  art  of  laryngoscopy  is  based  is 
simply  that  of  the  well-known  optical  law,  that  when  a  ray  of 
light  falls  on  a  plane  surface,  the  angle  of  reflection  is  equal  to  the 
angle  of  incidence  (Fig.  XXV.).  Thus  the  light  (l),  being  thrown 
from  the  reflector  (r)  on  to  the  laryngeal  mirror  (m)  placed  at  the 
back  of  the  mouth,  illuminates  the  larynx  (v),  and,  by  a  reduplica- 


FiG.  XXVI.— Diagram  of  Laryngeal  Mirror,  Illustrating  the  Reversion 
OF  the  Reflected  Image. 

tion  of  the  same  law,  the  image  (v.  i)  of  the  illuminated  larynx  is 
reflected  on  to  the  laryngeal  mirror,  and  may  there  be  seen  by  the 
eye  of  the  observer  (o).  It  is  important  to  remember  that  this 
reflected  image  is  laterally  symmetrical  of  the  object,  and  not 
reversed  ;  that  is  to  say,  what  is  right  and  left  in  the  larynx  of 


48 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  patient  remains  right  and  left  in  the  mirror.  At  the  same 
time,  it  must  of  course  be  remembered  that  the  patient's  right 
corresponds  with  the  observer's  left,  and  vice  versa  (Fig.  XXVI.). 
The  only  inversion  which  takes  place  is  in  the  antero-posterior 
direction — the  epiglottis,  which  in  the  patient's  larynx  is  in  front, 
nearest  to  the  observer,  appearing  at  the  upper  part  of  the  mirror, 
whilst  the  posterior  part  of  the  larynx  appears  in  the  lower  part 
of  the  mirror  (Fig.  XXVIL). 

The  relative  horizontal  levels  of  the  different  parts  are  well 
preserved  ;  the  epiglottis  is  seen  to  be  on  a  higher  plane  than  the 
arytenoid  cartilages,  and  the  ventricular  bands  are  observed  above 
the  vocal  cords.  As  far  as  observation  is  concerned,  then,  the 
apparent  antero-posterior  inversion  is  of  no  importance,  but  it 
must  be  carefully  remembered  when  introducing  a  brush  or  other 
instrument  into  the  larynx. 

With  regard  to  the  furnishing  of  a  room  for  laryngoscopy,  very 
little  is  required.  M}^  own  room  is  arranged  as  follows  :  A  small- 
seated  moderately  hard  chair  with  an  upright  back  is  placed 
against  the  wall,  for  the  patient ;  in  front  of  this  is  an  ordinary 
chair  or  music-stool  for  the  observer.  On  the  left  of  the  patient's 
chair  is  a  pedestal-table,  with  the  examining-lamp,  a  carafe  of 
water,  a  tumbler,  and  a  spittoon.  The  table  is  constructed 
with  drawers  for  tongue-cloths,  instruments,  etc.  On  it  stands 
also  compressed-air  receiver  for  sprays,  etc.  On  the  left  is  a 
revolving  shelf-table  for  solutions,  etc.,  required  for  ordinary  use. 
It  will  be  seen,  from  the  simplicity  of  these  arrangements,  that 
laryngoscopic  examinations  may  be  made  in  any  room.  One 
thing  is  to  be  remembered — viz.,  to  place  the  patient  so  that  the 
da3dight  from  the  window  and  the  reflected  light  may  not  be  in 
antagonism. 

To  make  an  examination  of  throat  and  larynx  the  following 
steps  must  be  taken  in  the  order  named  : 

1.  Direct  the  patient  to  sit  erect,  with  the  knees  together  and 
the  head  slightly  thrown  back. 

2.  Arrange  the  lamp  so  that  it  is  distant  about  nine  inches  to 
the  left  of  the  patient's  head,  and  in  a  line  with  his  ear. 

3.  Sit  opposite  the  patient,  and  adjust  the  reflector  so  that  the 
right  eye  looks  through  the  central  perforation.  (By  this  arrange- 
ment both  the  observer's  eyes  ars  screened  from  the  glare  of  the 
light,  which  is  not  the  case  when  the  reflector  is  worn  in  the 
centre  of  the  forehead.) 

4.  Direct  the  patient  to  open  the  mouth  widely. 

5.  Throw  the  light  on  to  the  point  of  junction  of  the  uvula  with 
the  soft  palate,  according  to  the  focal  distance  of  the  reflector, 


EXAMINATION  OF  THE  THROAT  AND  LARYNX. 


49 


and  examine  thoroughly  the  parts  there  exposed,  such  as  the 
uvula,  tonsils,  fauces,  and  back  of  the  pharynx.    (See  Chap.  III.) 

6.  Take  the  laryngeal  mirror  in  the  right  hand,-^  and  slightly 
warm  it  over  the  lamp,  to  prevent  its  being  dimmed  by  the 
moisture  of  the  patient's  breath.  Test  the  w^armth  of  the  mirror 
by  placing  the  back  of  it  against  your  own  hand  or  cheek.  It 


Fig.  XXVII. — Position  of  Observer's  Hands  in  making  a  Laryngoscopic 

Examination. 

will  be  noticed,  when  holding  a  mirror  over  a  lamp,  that  the  glass 
becomes  covered  with  a  film  of  moisture,  which  soon  clears  away. 
The  moment  this  moisture  has  disappeared,  and  the  mirror  be- 
comes clear,  the  latter  is  at  the  right  temperature. 

Of  course,  ail  these  steps  may  be  taken  with  the  hands  reversed  ;  and  one  advantage 
of  holding  the  mirror  always  in  the  left  hand  is,  that  when  the  right  is  required  lor 
operative  measures,  the  laryngeal  mirror  can  be  held  in  the  opposite  hand  without  any 
sense  of  awkwardness.  In  this,  however,  as  in  all  surgical  procedures,  the  observer 
should  be  ambi-dextrous. 


4 


DISEASES  OF  THE  THROAT  AND  NOSE, 


7.  Direct  the  patient  to  protrude  the  tongue. 

8.  Gently  draw  the  same  forward  with  the  left  hand,  previously 
enveloped  in  a  small  cloth  or  napkin,  holding  the  organ  between 
the  thumb  and  index-finger  (Fig.  XXVII.)  the  former  being 
uppermost.    (See  below,  caution  B.) 

9.  Holding  the  mirror  like  a  pen  in  the  right  hand,  and,  follow- 
ing the  curve  of  the  hard  palate,  introduce  it  into  the  patient's 
mouth  with  the  reflecting  surface  directed  downwards,  and  then, 
holding  it  horizontally,  rest  its  back  gently  against  the  uvula  (Fig. 
XXVIL). 

10.  Turn  the  hand  slightly  towards  the  patient's  left,  so  as  to 
keep  it  out  of  the  line  of  view, 

11.  Direct  the  patient  to  take  a  deep  inspiration,  and  then  to 
utter  the  sounds  ah,  ttr,  eh,  or  ee. 

A  view  of  the  larynx  should  thus  be  obtained  (Fig.  XXVIL), 
and  the  vocal  cords,  which  are  easily  recognisable  by  their  pearly 
colour,  should  be  seen  separating  on  inspiration  and  approaching 
on  phonation. 

There  are,  however,  frequently  certain  difficulties  in  the  way 
in  making  a  laryngoscopic  examination,  and  they  may  be  divided 
into  two  classes — those  due  to  the  observer,  and  those  pertaining 
to  the  patient. 

The  pupil  should  constantly  bear  in  mind  the  motto,  '  Arte 
non  vi.'  He  must  not,  because  at  first  he  sees  only  the  base  of 
the  tongue  or  the  upper  surface  of  the  epiglottis,  at  once  make  up 
his  mind  that  the  patient  before  him  is  one  of  those  in  whom  it 
is  impossible  to  obtain  a  view  of  the  larynx.  On  the  contrary, 
he  must  examine  this  same  patient  carefully  each  day  until  he 
succeeds ;  for  it  cannot  be  too  strongly  insisted  on  that  the  pro- 
portion of  cases  in  which  a  skilled  laryngoscopist  is  unable  to 
obtain  a  satisfactory  picture  in  the  laryngeal  mirror  is  very 
small  indeed.  Attention  to  the  following  cautions  may  obviate 
failure  : 

A.  Be  careful  that  the  light  is  thoroughly  well  reflected,  and 

learn  to  keep  the  disc  of  light  steadily  directed  on  to  the 
fauces. 

B.  In  holding  the  tongue,  grasp  it  firmly  but  gently,  and  do 

not  draw  it  down  on  the  teeth,  so  as  to  hurt  the  frasnum 
or  otherwise  give  pain.  If  the  tongue  has  any  tendency 
to  be  elevated  at  the  dorsum,  it  is  worse  than  useless  to 
pull  at  it,  as  the  contraction  is  thereby  only  increased. 
In  such  cases  a  better  view  may  occasionally  be  gained 
by  directing  the  patient  to  hold  his  own  tongue,  or  by 


EXAMINATION  OF  THE  THROAT  AND  LARYNX.  51 

allowing  the  tongue  to  be  kept  within  the  mouth.  This 
last  alternative  should  always  be  adopted  by  preference 
in  the  case  of  singers,  or,  if  possible,  wherever  it  is 
desired  to  observe  the  movements  of  the  cords  in  the 
production  of  tone,  since  traction  on  the  tongue  is  apt  to 
distort  the  laryngeal  movements. 

C.  Be  very  careful,  after  warming  the  mirror,  to  test  its 

temperature  on  the  back  of  the  hand  or  cheek,  lest  it  be 
so  hot  as  to  be  disagreeable  to  the  patient. 

D.  Be  careful  not  to  touch  the  tongue  with  the  mirror  when 

introducing  it. 

E.  Press  the  uvula  very  gently  upwards  and  backwards,  but 

do  not  force  it  against  the  posterior  wall  of  the  pharynx, 
or  retching  and  gagging  will  immediately  ensue. 

F.  When  the  mirror  is  introduced,  adapt  the  exact  angle  to 

the  relation  which  the  plane  of  the  larynx  bears  to  the 
position  both  of  patient  and  observer,  and  do  not  too 
quickly  decide  that,  because  at  first  only  the  epiglottis 
or  the  posterior  commissure  is  seen,  therefore  an  image 
of  the  rest  of  the  larynx  is  unattainable. 

G.  Let  each  examination  be  very  short,  especially  on  the 

first  occasion  of  seeing  a  patient.  The  mirror  may  then 
be  introduced  six  or  eight  times  without  producing 
spasm  or  nausea,  whereas  if  the  mirror  be  too  long 
retained,  irritation  of  the  fauces  will  frequently  be  pro- 
duced, and  all  efforts  at  further  examination  will,  for 
that  occasion  at  least,  be  unsuccessful.  Besides  the 
annoyance  this  will  cause  the  observer,  there  is  the  fear 
that  the  patient  may  lose  confidence  and  be  unwilling  to 
submit  to  further  examination  or  treatment. 
The  difftculties  on  the  part  of  the  patient  are  either  mental  or 

physical :  of  the  mental,  the  chief  is  the  apprehension  that  the 

instrument  will  hurt ;  therefore — 

H.  Take  the  trouble,  especially  with  children  and  female 

patients,  to  explain  that  the  process  is  simply  a  method 
of  examination,  and  that  it  is  in  no  sense  an  operation. 

I.  Wherever  apprehension  or  timidity  exists  on  the  part  of 

the  patient,  it  is  often  well  to  introduce  the  mirror  gently 
into  the  mouth  once  or  twice,  and  to  quickly  withdraw 
it,  before  any  real  attempt  is  made  to  examine  the 
larynx. 

Intolerance  of  laryngoscopy  is  rarely  due  to  any  physical  cause 
on  the  part  of  the  patient,  but  is  almost  always  the  result  of 


52 


DISEASES  OE  THE  THROAT  AND  NOSE. 


nervousness.  It  may,  however,  be  caused  by  the  disease  under 
which  the  patient  labours  ;  for  example,  a  patient  suffering  from 
simple  congestion  or  relaxation  of  the  mucous  membrane,  or  from 
phthisis,  is  more  intolerant  of  anything  touching  the  uvula  or 
posterior  wall  of  the  pharynx  than  is  a  patient  suffering  from 
syphilitic  disease  or  lupus.  In  chronic  granular  hypertrophy  of 
the  vault  of  the  pharynx  there  is  reflex  irritation,  which  produces 
spasm,  retching,  and  gagging.  In  almost  all  affections  of  the 
motor  nerves  of  the  larynx  there  is  some  co-existent  diminution  of 
sensibiHty;  and  few  cases  present  less  difficulty  in  the  way  of 
satisfactory  laryngoscopic  examination  than  that  of  a  patient 
suffering  from  functional  aphonia. 

Of  all  artificial  methods  of  reducing  intolerance  of  laryngoscopy 
none  is  better  than  to  cause  the  patient  to  suck  small  pieces  of 
ice  for  a  few  minutes,  and  should  it  not  be  available,  sipping  cold 
water,  or  gargling  with  the  same  by  the  Von  Troeltsch  method  as 
described  at  page  102,  in  Chapter  VII.,  will  frequently  have  a 
similarly  satisfactory  effect.  In  more  extreme  cases,  especially 
where  intolerance  is  due  to  pathological  causes,  the  painting  or 
spraying  the  soft  palate  with  a  5  or  10  per  cent,  solution  of  hydro- 
chlorate  of  cocaine  will  render  easy  an  examination  which  might 
otherwise  have  been  difficult  or  impossible.  It  is  better  on  every 
account  to  repeat  application  of  a  weak  solution  than  to  employ 
a  stronger  one  as  often  recommended.  As  to  instruments  of  the 
nature  of  the  *  Throat  Educator,'  which  the  patient  is  frequently 
to  introduce  into  his  throat,  so  as  to  diminish  its  sensitiveness  to 
instruments,  I  am  bound  to  say  that  I  have  never  yet  met  with 
cases  in  which  such  a  measure  was  necessary.  The  gentle  hand 
and  encouraging  word  will,  in  my  experience,  do  more  than  any 
other  training.  All  mechanical  appHances  for  holding  the  uvula 
or  for  fixing  the  patient,  invariably  act  as  hindrances  rather  than 
as  aids  to  the  observer. 

The  difficulties  due  to  the  conformation  of  the  larynx  itself, 
and  the  best  methods  of  overcoming  them  will  be  treated  in 
the  description  of  the  laryngoscopic  image  in  the  fourth  chapter- 
It  often  happens  that  a  view  of  the  posterior,  or  oesophageal, 
aspect  of  the  larynx,  and  especially  of  its  sub-glottic  portion,  is  not 
easily  obtainable.  In  these  circumstances  the  method  described 
by  -Dr.  Killian,  of  Fribourg,  may  be  adopted.  The  patient  should 
either  sit  in  a  high  chair  or  stand,  and  holding  the  head  well 
forward,  should  flex  the  chin  down  on  to  the  chest;  he  should 
further  be  directed  to  control  his  own  tongue  with  the  cloth.  The 


EXAMIIVA  TION  OF  THE  THRO  A  T  AND  LAR  YNX.  53 


observer  should  either  kneel  or  '  squat,'  and,  looking  upwards, 
should  pass  the  mirror  as  far  backwards  as  possible.  By  pursuing 
these  manoeuvres — modifying  the  details  according  to  the  varying 
conditions — a  satisfactory  image  of  the  posterior  laryngeal  wall 
can  often  be  obtained. 

A  few  words  remain  to  be  said  concerning  Laiyngoscopy  in 
Children.  I  entirely  agree  with  ^Schroetter,  ^Lefferts,  and  others, 
that  those  physicians  are  mistaken  who  declare  it  to  be  im- 
possible or  exceptional  to  make  a  satisfactory  laryngoscopic  exami- 
nation— or  even  a  posterior  rhinoscopic — in  the  case  of  children  ; 
and  I  as  emphatically  dissent  from  the  opinion  of  those  who  con- 
sider force  necessary.  On  the  contrary,  such  a  course  only  leads 
to  resistance  and  failure  of  consent  to  a  second  attempt.  In  my 
own  practice  I  take  every  step  exactly  as  with  an  adult,  only 
differing  in  perhaps  saying  less  rather  than  more  to  the  patient 
beforehand,  for,  telling  a  child  that  he  is  not  going  to  be  hurt  is 
often  the  first  suggestion  that  he  may  be.  As  to  position,  the 
child,  if  under  seven,  should  be  examined  sitting  on  the  lap  of  the 
mother  or  nurse,  who  is  to  be  directed  to  hold  herself  upright  and 
support  the  child  against  her  chest  with  her  hands,  one  on  each 
side  of  the  head.  If  over  seven  years  of  age,  I  make  the  child 
stand  up  instead  of  sit,  unless  a  chair  higher  than  that  ordinarily 
used  for  adults  is  available. 

The  chief  difficulties  in  the  way  of  infantile  laryngoscopy  are  : 
first,  the  possibility  that  the  child  will  not  open  the  mouth; 
secondly  that  he  will  not  protrude  the  tongue ;  and  thirdly,  that, 
the  epiglottis  being  more  frequently,  and  to  a  greater  degree 
pendant  in  children  than  in  adults,  a  view  even  in  otherwise 
favourable  circumstances  will  be  unattainable  or  very  partial. 
The  first  hindrance  will,  in  the  majority  of  cases,  be  overcome 
with  a  little  patience ;  but  should  the  refusal  be  obstinate,  com- 
pression of  the  nostrils  for  a  second  or  two  will  soon  cause  the 
little  patient  to  open  his  mouth,  from  the  necessity  to  iake  breath. 
As  to  the  second  it  is  by  no  means  absolutely  necessary  that  the 
tongue  should  be  protruded ;  and  the  third  obstacle,  the  others 
having  been  overcome,  is  often  removed  if  the  surgeon  is  on  the 
alert  to  take  advantage  of  reflex  '  gagging,'  w^hich  act  he  may  even 
usefully  stimulate  by  a  little  extra  pressure  of  the  laryngeal  mirror 
against  the  fauces. 

To  prove  that  laryngoscopic  procedure  is  not  impossible,  it  may 
be  noted  that  Fig.  55  on  Plate  VI.  of  laryngeal  diphtheria,  in  a 
child  aged  four,  was  drawn  from  nature,  and  I  have  operated 


S4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


repeatedly  for  laryngeal  growths  in  a  child  between  six  and  seven 
years  of  age.  Schroetter  mentions  that  he  has  seen  inside  the 
larynx  of  a  child  six  months  old,  and  I  think  I  may  say  that  I 
have  often  succeeded  in  obtaining,  if  not  a  complete  view,  at 
least  useful  indications  towards  establishing  or  confirming  a 
diagnosis  in  children  quite  as  young. 

Finally  it  may  be  mentioned  that  in  the  rare  cases  in  which  the 
obstacles  to  laryngoscopic  examination  of  a  child  are  insuperable, 
a  view  may  often  be  obtained  of  the  interior  of  the  larynx,  on 
account  of  its  higher  position  in  the  throat  in  children,  by  rather 
forcible  depression  of  the  base  of  the  tongue  with  a  spatula. 
Moreover  it  is  not  at  all  impracticable  to  get  a  view  of  the  larynx 
of  the  infant  under  influence  of  an  anaesthetic,  which  may  be 
either  partial  or  complete.  In  such  a  case  it  is  of  course  advis- 
able to  enforce  the  usual  precautions  of  fasting  from  food,  so  as  to 
avoid  vomiting.  For  the  purpose  of  examination  the  little  patient 
should  be  held  by  the  nurse  in  the  ordinary  laryngoscopic  position. 
A  mouth-dilator  or  prop  is  essential. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 


NO. 


NAME. 


TITLE  OF  WORK  REFERRED  TO. 


53 


53 


4 


3 


Schroetter. 


KiLLIAN. 


ISAMBERT. 


Lefferts. 


(    i.,  p.  232  ;  and  '  Discussion,'  p.  36S. 


CHAPTER  III. 


INSPECTION  OF  THE  MOUTH,  FAUCES,  AND  ORO  PHARYNX. 

As  has  been  indicated  in  Rule  5  of  the  steps  to  be  taken  for 
making  examinations  of  the  larynx  (Chapter  II.,  p.  48),  thorough 
inspection  should  in  all  cases  be  made  of  the  parts  visible  to  the 
unaided  eye  as  a  prehminary  to  use  of  the  mirror  ;  first,  in  order 
that  the  observer  may  not  be  searching  for  a  cause  of  disease  in 
the  larynx  which  is  in  truth  much  nearer  at  hand  ;  and,  secondly, 
because  the  condition  of  the  fauces  and  other  supra-glottic 
structures  as  seen  in  the  open  mouth  will  often  afford  valuable 
indications  of  what  he  may  expect  to  see  on  employment  of  the 
laryngoscope  or  rhinoscope. 

Prior,  therefore,  to  consideration  in  detail  of  the  parts  com- 
prehended in  the  laryngoscopic  image,  it  will  be  useful  to  briefly 
pass  in  contemplation  the  various  structures  brought  to  view 
when  the  light  from  our  reflector  is  thrown  into  the  patient's 
open  mouth.  In  my  own  practice  I  always  attempt,  in  the  first 
instance,  to  see  the  throat  without  employment  of  a  spatula  or 
tongue-depressor ;  but,  as  a  matter  of  fact,  very  few  patients — 
only  such  as  have  undergone  proper  training,  as  singers — can 
keep  their  tongue  under  control,  and  on  this  account  some  form 
of  instrument  is  almost  always  necessary.  A  paper-knife  or 
spoon-handle,  always  ready  to  hand,  will  frequently  answer  for 
all  that  is  needed ;  but  for  the  consulting-room  a  special  de- 
pressor is  indispensable.  My  own  experience  leads  me  to  say 
that  the  best  form  of  instrument  is  Frankel's,  the  blade  of  which 
is  not  so  broad  as  to  cause  reflex  elevation  of  the  dorsum 
of  the  tongue,  while  the  end  being  fenestrated  may  often  be 
utilized  for  lifting  up  the  uvula.  The  handle  is,  moreover,  so 
arranged  as  to  keep  the  hand  holding  it  away  from  the  line  of 
vision.  This  instrument  as  used  by  me  is  slightly  different  from 
that  usually  sold  by  the  makers,  inasmuch  as  its  under  surface  is 
roughened.    When  placed  in  position  it  may  be  entrusted  to  the 


56 


DISEASES  OF  THE  THROAT  AND  NOSE. 


patient,  a  valuable  proviso,  because  pressure  upon  the  base  of  the 
tongue  (necessary  in  rhinoscopy)  is  less  apt  to  produce  retching 
when  its  amount  is  controlled  by  the  patient  himself. 

On  the  first  examination  of  a  patient,  and  especially  if  made  by 
a  surgeon  not  accustomed  to  the  process,  gagging  and  retching  will 
often  occur,  the  tongue  resisting  all  attempts  to  control  it.  It  is 
worthy  of  note  that  pressure  on  that  portion  of  the  tongue  anterior 
to  the  sulcus  terminalis — that  is  to  say,  that  portion  supplied  by  the 
fifth  nerve — is  remarkably  tolerant  of  such  manipulation,  whilst 
very  moderate  pressure  behind  that  line,  in  the  region  supplied  by 
the  glosso-pharyngeal  nerve,  is  immediately  resisted.  This  physio- 
logical fact  may  often  be  turned  to  account,  or  even  stimulated, 
as  first  advised  by  ^Voltolini,  when  it  is  desired  to  bring  more  of 
the  back  of  the  throat  into  view  than  would  otherwise  be  effected, 


Fig.  XXVIII.— Hill's  Folding  Tongue  Depressor  and  Retractor  (Half 

M  E  A  s  u  r  e  m  e  n  t  s  ) . 

especially,  for  instance,  in  cases  of  disease  of  the  tonsils,  pillars  of 
the  fauces,  or  base  of  the  tongue  ;  but  in  order  to  avoid  such  reflex 
movements,  certain  hints  may  be  acceptable :  i,  not  to  place  the 
depressor  too  far  back  on  the  tongue ;  2,  not  to  exert  too  great 
pressure  thereon  ;  and  3,  to  depress  in  the  middle  line,  and  pre- 
ferably with  a  narrow  instrument ;  observance  of  these  hints  will 
go  far  to  prevent  reflex  contraction  and  arching  of  the  tongue, 
which  is  the  first  and  commonest  hindrance  to  a  throat  examina- 
tion. Hill's  instrument  (Fig.  XXVIII.)  is  convenient  on  account 
of  its  folding  and  consequently  greater  portability,  and  useful  be- 
cause it  possesses,  in  addition  to  the  merits  of  Frankel's  depressor^ 
a  powerful  retractor,  which  is  very  serviceable  in  examination  of 
the  base  of  the  tongue.  ^Baber's  suggestion  of  a  thimble  tongue- 
depressor  has  certain  advantages,  and  its  utility  in  an  extended 


INSPECTION  OF  THE  MOUTH  AND  FAUCES. 


57 


degree  has  long  been  recognised  in  my  practice,  not  only  for 
general  throat  examinations,  but  as  especially  serviceable  for 
children,  concerning  whom  two  other  difficulties  in  the  way  of 
satisfactory  inspection  are  to  be  mentioned.  In  the  first  place, 
there  is  often  resistance  to  open  the  mouth  at  all ;  and,  secondly, 
when  it  is  open  it  is  often  closed  on  the  spatula  as  soon  as  intro- 
duced, or  on  the  surgeon's  finger,  if  imprudently  placed  there, 
a  procedure  which  is  even  recommended  by  ^Cohen.  -These  diffi- 
culties are  overcome  by  the  surgeon  compressing  the  nostrils  of 
the  little  patient  with  the  left  hand.  In  a  couple  of  seconds  the 
mouth  is  of  necessity  opened  for  breath,  and  he  should  then  deftly 
introduce  a  spatula,  or  his  finger  protected  by  a  guard.  Directly 
the  patient  opens  the  mouth  the  surgeon  will  find  himself  further 
protected  against  being  bitten,  if  he,  with  his  left  hand,  presses  the 
patient's  left  cheek  between  the  upper  and  lower  teeth.    Lately  I 

Fig.  XXIX. — Wingrave's  Automatic  Mouth-Prop. 

By  means  of  a  spiral  spring  the  instrument  expands  when 
the  mouth  is  opened,  and  remains  jammed  at  the  furthest 
point  of  expansion,  so  that  no  pressure  of  the  jaw  can  close 
it  until  the  operator  presses  the  thumb-rest.  The  tooth- 
sockets  are  mounted  on  swivels,  so  that  the  prop  may  be 
pushed  to  one  side  or  the  other  to  suit  any  operation,  whether 
right,  left,  or  central. 

have  abjured  the  metal  guard  I  formerly  employed,  first  for  a 
leather  one,  devised  by  Grant,  and  later  for  the  still  more  simple 
one  of  Hovell,  which  consists  of  a  piece  of  thick  india-rubber 
tubing  covering  the  proximal  phalanx  of  the  index  finger  (Fig. 
CCXXIV.).  For  examination  of  the  post-nasal  space,  as  well  as 
for  operations  under  anaesthesia,  Wingrave's  mouth-prop  (Fig. 
XXIX.)  is  invaluable. 

The  normal  colour  and  appearances  of  the  open  mouth  are 
sufficiently  familiar  even  to  non- medical  persons  to  make  detailed 
description  unnecessary ;  and  in  reviewing  the  different  parts 
brought  into  vision  I  shall  content  myself  with  giving  brief  indi- 
cations of  what  we  may  learn  by  simple  inspection,  for  the  better 
diagnosis  of  disease,  in  this  region.  After  the  first  general  glance, 
which  should  satisfy  the  observer  as  to  hypersemia  or  anaemia, 
enlargement,  inflammation,  or  ulceration,  adventitious  deposits, 
or  new-growths  on  tonsils,  uvula,  and  other  parts,  each  separate 
oral  structure  may  be  explored. 


58 


DISEASES  OF  THE  THROAT  AND  NOSE. 


1.  The  Teeth  should  be  observed  principally  {a)  for  the  indica- 
tions of  inherited  diatheses  of  struma,  syphiHs,  and  the  like  ;  (6) 
as  sources  of  irritation  in  the  cases  of  inflammations,  cracks,  and 
ulcers  in  the  mouth  or  on  the  tongue  ;  (c)  for  completeness  or 
deficiency  in  number,  in  cases  of  dysphagia,  to  be  possibly  ac- 
counted for  by  imperfect  mastication,  *  bolting '  of  the  bolus,  and 
consequent  fatigue  and  paresis  of  the  pharyngeal  constrictors ; 
{d)  if  any  of  the  teeth  are  artificial  they  should  for  the  same 
reason  be  inspected  for  the  purpose  of  ascertaining  whether  in 
the  case  of  molars  the  upper  and  lower  meet  so  as  to  effect  their 
purpose,  and  they  should  always  be  removed  and  search  be  made 
for  any  irritation  their  presence  may  have  engendered  ;  (e)  as 
certain  cases  of  unilateral  nasal  discharge  may  arise  from  abscess 
of  the  antrum,  note  should  be  made  of  absence  of  teeth  or  of 
presence  of  decayed  stumps  likely  to  have  been  the  origin  of  sup- 
puration in  this  region. 

2.  The  Gums  should  be  well  examined  {a)  for  indications  of 
mercurial,  lead,  or  other  mineral  poisoning ;  [h)  for  various  in- 
flammations, fungi,  and  new-growths  ;  (c)  for  manifestations  of 
idiopathic,  syphilitic,  lupous,  or  tuberculous  ulcers  ;  and  {d)  as  an 
indication  of  the  condition  of  health  of  the  blood-supply  (anaemia, 
scurvy,  etc.). 

3.  The  Tongue  requires  careful  examination  on  account  of  both 
the  local  and  general  significance  of  its  appearances.  It  presents 
many  shght  differences  in  size,  surface,  and  firmness  of  texture, 
which  are  not  really  departures  from  the  normal ;  but  as  there  are 
many  diseased  conditions  of  this  organ  which  come  under  the 
notice  of  the  throat  specialist,  its  varying  appearances  should  be 
thoroughly  studied  and  mastered,  so  that  judgment  can  be  formed 
as  to  {a)  '  tone  '  indications  of  the  general  constitutional  state, 
notably  those  of  colour  and  secretion ;  {h)  presence  or  extension  of 
more  or  less  local  manifestations,  syphiHs,  cancer,  tubercle, 
ranula,  etc.,  as  evidenced  by  asymmetry  or  impaired  mobility ; 
and  {c)  as  a  cause  of  reflex  throat  symptoms,  of  which  enlarge- 
ment of  the  lymphoid  tissue,  or  lingual  tonsil,  and  varix  of  the 
base  may  be  named.  For  exploration  of  these  last  the  laryngeal 
mirror  is  generally  necessary,  though  sometimes  the  whole  tongue, 
and  even  the  lingual  surface  of  the  epiglottis,  can  be  seen  without 
any  such  adventitious  aid,  and  especially  if,  as  previously  stated, 
the  depressor  is  placed  so  far  back  as  to  stimulate  retching. 

4.  The  Buccal  Lining  of  the  oral  cavity  is  the  last  part  to  be 
explored  before  coming  to  the  throat  proper.    Normally,  it  is 


INSPECTION  OF  THE  MOUTH  AND  FAUCES. 


59 


of  a  warm  pink  colour,  as  of  boiled  salmon  ;  but  its  hue  varies, 
being  paler  over  the  hard  palate,  where  it  is  more  firmly  attached 
than  at  the  sides,  the  lips  and  soft  palate.  Independently  of  the 
various  inflammations  comprehended  under  the  term  stomatitis, 
this  region  is  to  be  viewed  for  syphilitic,  diphtheritic,  tuberculous, 
lupous,  and  other  manifestations.  In  the  cases  of  certain  skin 
affections,  as  eczema,  herpes,  etc.,  there  are  often  more  or  less 
analogous  conditions  of  the  oral  lining. 

5.  The  Soft  Palate  and  Fauces  (Fig.  XXX.)  hardly  require 
detailed  description.    Their  colour  is  generally  that  of  the  rest  of 


Fig.  XXX.— The  Oral  Cavity. 

1.  Soft  palate.  3  and  4.  Anterior  pillars  of  fauce;; 

2.  Uvula.  5  and  6.  Posterior  pillars  of  fauces. 

7  and  8.  The  tonsils. 

the  buccal  mucous  membrane,  but  is  of  deeper  hue  at  the  pillars 
(Fig.  XXX.,  3,  4,  and  5,  6).  Impairment  of  its  muscular  tone 
(paresis)  is  generally  tested  by  observation  of  its  pendulous  portion. 

6.  The  Uvula  (Fig.  XXX.,  2),  the  anatomy  of  which  has  been 
already  described  (p.  27),  is  a  very  important  structure,  and  its 
appearance  greatly  varies  according  to  the  method  employed  in 
its  inspection.  When  a  patient  opens  the  mouth  he  generally 
takes  a  deep  inspiration,  which  has  the  effect  of  drawing  the  uvula 
up.  For  the  purpose  of  a  proper  examination  of  the  uvula,  the 
patient  should  be  directed  (a)  to  open  the  mouth  without  inspiring 
— this  will  give  an  idea  of  its  usual  position  in  repose ;  (b)  to  sing 
up  the  scale — this  will  indicate  its  power  of  contraction  ;  (c)  to 
breathe  through  the  nostril  with  open  mouth — this  will  show  it  in 


6o  DISEASES  OF  THE  THROAT  AND  NOSE. 

its  state  of  greatest  laxity.  By  these  steps,  and  by  observation  of 
the  relative  size  and  length  of  the  uvula  to  the  arch  of  the  soft 
palate,  data  will  be  provided  for  forming  a  judgment  as  to  the  part 
played  by  this  member  in  a  case  of  throat  disease.  Passing 
further  remark  regarding  the  pillars  of  the  fauces,  the  anatomy  of 
w^hich,  as  of  the  rest  of  the  soft  palate,  has  already  been  con- 
sidered, we  must  note — 

7.  The  Tonsils  (Fig.  XXX.,  7  and  8)  w^hich,  as  previously 
stated  (p.  28),  lie  betw^een  the  faucial  pillars.  The  normal  range 
of  their  size,  etc.,  varies  greatly,  but  generally  it  may  be  stated 
that  in  health  they  should  not  protrude  beyond  the  plane  of  the 
anterior  pillars.  Nor  is  their  size  the  only  thing  to  be  observed, 
as  when  atrophied  they  may  often  be  diseased.  Needless  to  add 
also  that  local  evidences  of  specific  dyscrasicc  are  often  to  be  seen 
on  the  tonsils.    (See  Chap.  XI.) 

8.  The  amount  of  the  Pharynx  seen  without  either  the  laryngeal 
or  posterior  rhinoscopic  mirror  is  that  confined  to  the  middle  or 
oro-pharyngeal  portion.  In  colour  it  is  normally  redder  than  the 
mucous  membrane  of  the  mouth.  It  is  generally  smooth,  moist, 
and  lustrous,  but  may  be  slightly  uneven  or  wavy  in  surface  within 
the  range  of  health.  Veins  of  varying  distinctness  and  promi- 
nence are  also  to  be  seen  coursing  over  it.  ^Cohen  says :  '  The 
pharynx  often  appears  deeper  on  one  side  (usually  the  right)  than 
the  other,  owing  to  a  similar  conformation  of  the  anterior  bodies 
of  the  vertebrae.  When  the  constrictor  muscles  of  the  pharynx 
contract,  as  they  often  do  involuntarily  during  inspection,  they 
draw  the  posterior  palatine  folds,  into  which  they  have  insertion, 
towards  each  other,  so  that  they  nearly  or  even  actually  meet, 
shutting  the  mouth  off  from  the  pharynx.  The  sensitiveness  of 
the  parts,  and  the  amount  of  mucus  and  saliva  present,  vary 
greatly  within  normal  limits.'  This  part  offers  important 
indications  of  disease,  which  may  extend  either  upwards  to  the 
nasal  or  downwards  to  the  laryngeal  portion,  and  must  therefore  be 
thoroughly  studied  in  regard  to  its  colour,  surface,  secretion,  etc. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

TITLE  OF  WORK  REFERRED  TO. 

~  .56 
56 

57 

60 

2 

3 
4 

VOLTOLINI. 

C.  Baber. 
SoLis  Cohen. 

Galvanokaitstik.,  Wien,  1872,  p.  72. 
f  A  Gtcide  to  Examination  of  the  Nose^ 
\     London,  1886,  p.  103. 
j  Diseases  of  the  Tliroat  and  Nasal  Passag^es^ 
\     2nd  edition,  New  York,  1S79,  p.  9. 

Ibid.,  p.  13. 

See  also  Diseases  of  the  Mottth,  Throat  and  Nose,  by  Schech,  of  Munj."Ji,  translated  into 
English  by  R.  H.  Blaikie,  M.D.,  Edinburgh,  1886. 


CHAPTER  IV. 

THE  LARYNGOSCOPIC  IMAGE. 

{See  Lithographic  Plate  I.  at  end  of  Book.) 

We  have  seen  that  the  laryngoscope  reveals  to  us  an  image  of 
the  interior  of  the  larynx,  and  we  have  divided  the  organ,  for 
practical  purposes,  into  three  compartments — the  first,  or  supra- 
glottic  ;  the  second,  or  glottic ;  and  the  third,  or  infra-glottic, 
taken  in  order  respectively  from  above  downwards.  In  looking 
at  the  reflection  in  the  laryngeal  mirror  of  a  typically  healthy 
larynx  (Plate  I.,  Fig.  i,  at  the  end  of  this  volume),  all  the  three 
divisions  may,  on  deep  inspiration,  be  seen  ;  but,  in  not  a  few 
instances,  the  beginner  will  see  only  the  epiglottis,  and  perhaps 
the  arytenoid  cartilages.  This  may  arise  either  from  the  fault  of 
the  observer,  who  has  not  sufficiently  followed  the  directions  or 
recognised  the  cautions  given  in  the  first  chapter,  or  from  the  fact 
that  the  epiglottis  is  really  so  situated  as  to  practically  obstruct 
the  view. 

The  accompanying  woodcuts  (Figs.  XXXI. ^  and  XXXII.*) 
show  the  two  extremes  of  the  views  which  will  be  obtained, 
according  to  the  angle  of  the  mirror  with  the  perpendicular  plane 
of  the  larynx,  and  also  to  the  horizontal  level  at  which  the 
mirror  is  placed  in  the  throat,  as  shown  in  Figs.  XXXI.  and 
XXXII. 

Before  entering  minutely  into  the  appearance  presented  by 
each  structure  when  reflected  in  the  mirror,  Plate  I.  should  be 
carefully  studied,  especially  the  two  first  figures,  in  order  that  the 
reader  may  become  perfectly  familiar  with  what  should  be  ob- 
served in  the  living  subject.  The  laryngeal  image  will  be  seen  to 
be  circular  in  shape  (though  this,  of  course,  would  vary  with  the 
shape  of  the  mirror  employed)  and  to  be  bounded  by  well-defined 
walls,  as  would  be  expected  at  the  opening  of  a  tunnel  like  the 
larynx.  The  epiglottis  will  be  seen  to  be  attached  to  the  base  of 
the  tongue,  forming  the  anterior  arch  of  the  tunnel,  and  occupy- 


62 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ing  the  foremost  and  uppermost  position  in  the  plane  of  the  larynx. 
From  each  side  the  folds  connecting  this  valve  with  the  arytenoid 
cartilages  complete  the  circle,  and  in  the  folds  may  be  seen  the 
prominences  of  the  arytenoid  and  their  supplementary  cartilages. 
On  a  lower  plane  are  the  two  ventricular  bands,  reduplications  of 
the  mucous  membrane  of  the  larynx,  containing  at  their  free  edge 
the  thro-arytenoid  ligaments.  These  form  the  floor  of  the  first  or 
supra-glottic  division  of  the  larynx.  At  first  sight  the  ventricle 
shows  only  as  a  dark  line  between  the  ventricular  bands  forming 
its  superior,  and  the  oval  ends  forming  its  inferior,  boundary;  but 


XXXI. 


Fig.  XXXI, — Sectional  View,  showing  the  Position  of  the  Head  of  the 
Patient,  and  of  the  Laryngeal  Mirror,  which  will  give  the  Minimum 
Amount  of  View.  The  Laryngoscopic  Image  in  such  a  Case  is  repre- 
sented IN  the  Smaller  Figure  at  the  Side,  XXXI."'' 

on  turning  the  mirror  so  as  to  get  a  lateral  view  of  one  or  other 
side  of  the  larynx  (Fig.  XXXIII.,  p.  64),  the  open  space  of  the 
ventricle  will  be  seen  to  be  much  larger  than  it  appears  when 
looking  directly  down  the  centre  of  the  larynx,  as  is  done  with  the 
usual  position  of  the  mirror.  It  will  be  further  seen  that,  by 
muscular  action,  this  space  varies  in  shape  and  size  in  different 
movements  of  the  larynx. 

Below  this  is  seen,  standing  out  in  bold  relief,  the  superior  sur- 
face of  the  vocal  cords,  which  ghsten  like  mother-of-pearl,  and 
move  to  and  fro  with  respiration  and  phonation.    Beneath  the 


THE  LARYNGOSCOPIC  IMAGE. 


63 


vocal  cords  are  seen  less  completely  the  contents  of  the  third  or 
infra-glottic  region.  A  portion  of  the  cricoid  cartilage  will  be 
observed,  then  some  rings  of  the  trachea,  and  further  on,  in  rare 
and  favourable  cases,  the  bifurcation  of  the  trachea,  the  right 
bronchus  being  the  larger  and  the  more  visible.  Outside  the 
larynx  are  seen  the  hyoid  fossae  and  the  anterior  border  of  the 
pharynx  as  far  as  the  commencement  of  the  oesophagus. 

Let  us  now  examine  more  minutely,  by  means  of  Plate  I. 
(which  should  be  opened  so  as  to  lie  beside  these  pages  during 


XXXII. 


Fig.  XXXII. — Sectional  View,  showing  the  Position  of  the  Head  of  the 
Patient,  and  of  the  Laryngeal  Mirror,  which  will  give  a  Full  Amount 
of  View.  The  Laryngoscopic  Image  in  such  a  Case  is  rei'resented  in  the 
Smaller  F'igure  at  the  Side,  XXX IL* 

perusal  of  the  chapter),  each  of  the  structures  thus  seen  on  a 
general  view  of  the  larynx.  All  the  numerals  in  the  following 
description  refer  to  this  plate.  And  once  again,  the  reader 
is  reminded  that  in  this  illustration  no  attempt  has  been 
made  to  reproduce  the  exact  colour  of  the  mucous  membrane, 
since  its  hue  varies  considerably  in  different  individuals,  just  as 
may  the  complexion  of  the  skin,  and  also  because  the  coloration 
is  altered  according  to  the  kind  of  light  employed  ;  such  as  sun- 
light, electric,  oxyhydrogen,  common  gas,  or  oil  lamps. 


64 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  Epiglottis  is  in  all  cases  the  first  object  of  which  a  reflec- 
tion is  seen  in  the  laryngeal  mirror,  and  appears  as  a  leaf-like 
piece  of  fibro-cartilage  connected  with  the  tongue  by  three  glosso- 
epiglottic  folds ;  viz.,  two  lateral  (l  g  e  f,  Fig.  i),  and  one 
superior  (s  G  E  F,  Fig.  7).  Attaching  it  to  the  inner  portion  of 
the  thyroid  cartilage,  just  above  the  anterior  commissure  of  the 
vocal  cords  (a  c.  Fig.  i),  is  seen  the  thyro-epiglottic  fold  (t  e  f. 
Fig.  2),  to  the  pharynx  the  two  pharyngo-epiglottic  folds  (p  e  f, 
Fig.  i),  and  to  the  arytenoid  cartilages  the  two  ary-epiglottic 
folds  (a  e  f,  Fig.  i).  In  some  instances  the  sulci  (anatomically 
termed  valleculae)  are  seen  in  the  mirror  on  the  upper  surface  of 
the  epiglottis.  They  are  situated  on  each  side  of  the  median  line, 
close  to  the  base  of  the  tongue,  and  they  are  bounded  by  the 
superior  and  lateral  glosso-epiglottic  folds  (Figs.  4,  7,  and  11). 
These  sulci  are  surgically  important  as  being  not  uncommonly 
the  seat  of  origin  of  specific  and  also  of  maligant  ulceration. 


Fig.  XXXIII. — A  Side  Vif.w  of  the  Larynx,  showing  the  Right 
Ventricle  of  Morgagni  ofen. 

/.  Left  vocal  cord. 

The  amount  of  the  epiglottis  visible  in  the  mirror  will  depend 
greatly  on  the  length  and  degree  of  tension  of  its  various  liga- 
ments ;  though,  as  has  been  said,  it  will  also  vary  according  to  the 
position  of  the  mirror.  For  example,  there  may  be  seen  at  one 
and  the  same  time  portions  of  the  superior  surface  (s  s  e,  Fig.  i), 
of  the  inferior  surface  (i  s  e),  of  the  cushion  (c  e),  and  of  the  free 
edge  or  lip  (l  e,  Fig.  2).  The  epiglottis  may  vary  greatly  in 
shape  :  it  ma}^  be  of  the  ordinary  curve,  and  show  a  portion  of 
both  the  superior  and  inferior  surfaces,  as  in  Figs,  i,  2,  and  11  ; 
it  may  be  so  pendulous  as  to  show  but  little  or  nothing  of  its 
inferior  surface,  as  in  Figs.  5,  7,  8,  and  9 ;  it  may  be  angular,  as 
in  Fig.  3  ;  folded  on  itself,  as  in  Fig.  4 ;  with  lip  but  slightly 
everted  and  doubly  curved,  as  in  Figs.  5  and  11  :  with  serrated  or 
obtusely  crenated  edge,  as  in  Fig.  6 ;  or  asymmetrical,  as  in 
Fig.  9 ;  lastly,  it  may  show  none  of  its  superior  surface,  but  stand 
quite  erect,  as  in  Fig.  10. 


THE  LARYNGOSCOPIC  IMAGE, 


65 


The  epiglottis  may  be  looked  upon  as  the  distinctive  feature  of 
the  larynx ;  for  no  part  is  so  variable  in  shape  and  size  ;  and  it 
thus  entirely  controls  the  individuality  of  the  organ.  This  is  not 
surprising,  because,  as  has  been  aptly  said,  there  is  no  more 
reason  why  the  epiglottis  should  be  uniform  than  that  all  noses 
should  be  alike. 

Although  it  is  true  that  the  epiglottis  may  vary  considerably 
in  shape  and  size,  and  yet  not  materially  interfere  with  the  view, 
as  is  seen  in  Figs,  i,  2,  3,  6,  8,  10,  and  11 ;  yet,  in  by  far  the 
majority  of  cases,  the  configuration  of  the  epiglottis  regulates  the 
amount  of  the  larynx  visible  in  the  mirror.  In  Fig.  4,  for  example, 
its  peculiar  form  prevents  the  posterior  part  of  the  cords  from 
being  seen ;  in  Fig.  5  little  more,  and  in  Fig.  7  no  more,  of  the 
larynx  is  visible  than  the  arytenoid  cartilages.  Occasionally  the 
papillae  of  the  tongue  may  be  so  enlarged,  and  the  glosso-epi- 
glottic  folds  so  lax,  as  almost  entirely  to  hide  the  epiglottis 
(Fig.  8) ;  and  this  appearance  may  easily  be  mistaken  for  disease 
of  the  valve  itself 

In  colour  the  epiglottis  may  be  likened  to  the  inner  surface  of 
the  eyelids.  It  is  of  a  warm  pinkish-yellow,  and  not  unfrequently 
capillary  vessels  may  be  seen  ramifying  over  its  surface  (Figs. 
5  and  6).  The  under  surface  is  always  of  a  deeper  colour  than 
the  upper,  the  cushion  itself  being  of  a  bright  red. 

During  respiration  the  epiglottis  remains  erect  ;  and  although 
it  moves  with  variations  of  vocal  notes,  it  plays  no  direct  part  in 
the  production  of  vocal  sound.  Its  special  office  is  to  close 
tightly  over  the  larynx  during  the  passage  of  food  into  the 
pharynx.  Any  affection,  therefore,  which  interferes  with  this 
movement  will  unavoidably  cause  discomfort  to  the  patient 
during  deglutition. 

Above  the  epiglottis  is  seen  more  or  less  of  the  base  of  the 
tongue,  with  the  folds  of  mucous  membrane  connecting  these  two 
parts,  to  which  reference  has  been  already  made.  Continuing  the 
circle  of  the  laryngoscopic  image,  there  will  be  seen  from  each 
side,  and  from  the  under-surface  of  the  lips  of  the  epiglottis,  the 
folds  of  mucous  membrane  connecting  it  with  the  arytenoid  car- 
tilages— the  aryteno-epiglottidean,  or,  more  shortly,  the  ary- 
epiglottic  folds  (a  e  f,  Fig.  i).  Generally,  only  the  superior  and 
a  portion  of  the  outer  or  pharyngeal  aspect  of  these  folds  is  visible, 
and  from  the  fact  that  the  ventricular  bands  (v  B,  Fig.  i)  are  alto- 
gether on  a  lower  level,  their  internal  or  laryngeal  side  is  not  seen 
in  the  mirror.  In  each  fold  may  generally  be  observed  two 
rounded  prominences,  that  nearer  the  epiglottis  being  the  carti- 

5 


66 


DISEASES  OF  THE  THROAT  AND  NOSE. 


lage  of  Wrisberg  (c  w,  Fig.  i),  and  that  nearer  the  median  Hne 
the  capitulum  of  Santorini  (c  s,  Fig.  i). 

The  two  capitula  of  Santorini  are  occasionally  seen  to  override 
each  other,  as  in  Fig.  lo.  In  many  cases  the  cartilage  of  Wris- 
berg  is  not  seen,  while  in  some  instances  a  third  small  prominence 
— that  of  the  sesamoid  cartilage  of  Liischka — is  visible  between 
those  of  Wrisberg  and  of  Santorini  (Fig.  8). 

Connecting  the  two  arytenoid  cartilages  is  the  inter-arytenc-id 
fold  (i  A  F,  Fig.  i),  forming  the  posterior  commissure  of  the  vocal 
cords  (p  c,  Fig.  2),  and  completing  the  circle  of  the  framework  of 
the  larynx. 

The  Ventricular  Bands,  formerly  called  false  vocal  cords  (v 
Fig.  i),  are  reduplications  of  the  mucous  membrane  continuous 
with  the  ary-epiglottic  folds,  to  which  they  are  attached  as  well  as 
to  the  under-surface  of  the  epiglottis  itself. 

At  the  median  line  the  mucous  membrane  of  this  fold  is  reflected 
back,  and  forms  the  lining  of  the  ventricle  of  Morgagni  (v  m. 
Figs.  I  and  6),  whence  it  again  issues  to  cover  the  vocal  cords, 
and  descend  into  the  trachea,  etc.  The  free  edge  of  the  ventricle 
is  somewhat  curved  in  shape,  and  encloses  the  thin  ligament 
(thyro-arytenoid)  running  from  the  inner  surface  of  the  angle  of 
the  thyroid  cartilage,  just  below  the  insertion  of  the  epiglottis,  to 
the  anterior  surface  of  the  arytenoid  cartilage. 

Occasionally  the  ventricular  bands  are  over-developed,  and  they 
then  approach  so  near  to  the  median  line  in  phonation  as  partially 
or  completely  to  hide  the  vocal  cords,  as  in  Fig.  11 ;  but  in  such  a 
case,  with  the  act  of  inspiration  the  vocal  cords  come  into  view. 

The  colour  of  the  ary-epiglottic  folds,  as  well  as  of  the  ventri- 
cular bands,  is  that  of  the  mucous  membrane  lining  the  cheeks, 
while  the  portion  covering  the  cartilages  may  be  described  as 
having  a  colour  similar  to  that  of  the  gums. 

Beneath  the  ventricles  are  seen  the  Vocal  Cords  (v  c.  Fig.  i)» 
They  are  at  once  recognised  as  two  lustrou-s,  fibrous  bands,, 
running,  when  closed  in  phonation,  almost  parallel  in  the  antero- 
posterior direction  of  the  larynx,  and  widely  separating  on  inspira- 
tion, the  widest  space  being  posteriorly.  Springing  from  the 
angle  of  the  thyroid,  and  attached  to  the  anterior  angle  of  the 
arytenoid,  each  cord  is  divided  into  two  portions — the  ligamentous 
or  anterior,  and  the  cartilaginous  or  posterior.  The  junction  oi 
these  tw^o  portions  is  at  the  point  known  as  the  vocal  process 
(v  P,  Fig,  2).  The  exact  anatomical  parts  representing  these 
processes  are  well  shown  on  Fig.  XII.,  6  and  7,  p.  20.  The  liga- 
mentous portion  of  the  vocal  cords  is  seen  to  be  of  a  glistening 


THE  LARYNGOSCOPIC  IMAGE. 


67 


pearly-grey  or  white  colour,  while  the  cartilaginous  part  is  often 
slightly  pink,  especially  in  the  case  of  those  who  are  constantly 
using  the  voice.  This  is  an  important  point  to  remember,  as 
otherwise  the  appearance  might  be  mistaken  for  the  result  of 
disease. 

It  is  well  to  notice  that  in  some  cases,  on  looking  into  the 
larynx,  the  anterior  commissure  is  not  seen,  but  that  the  pos- 
terior wall,  lying  in  cont'guity  to  the  oesophagus,  is  more  visible 
(Fig.  6).  In  such  cases  it  is  often,  but  erroneously,  supposed  that 
there  is  thickening  of  the  inter-arytenoid  fold. 

The  amount  of  the  Infra-glottic  division  of  the  larynx  visible 
in  the  laryngeal  mirror  varies  considerably  in  different  subjects. 
Generally,  the  internal  surface  of  the  anterior  portion  of  the 
cricoid  cartilage  (c  c.  Fig.  i),  and  two,  three,  or  more  rings  of  the 
trachea  will  be  seen  (t.  Fig.  i).  The  cartilaginous  rings  are  of  a 
yellowish-buff  colour,  the  interspaces  of  the  same  hue  as  the 
laryngeal  mucous  membrane.  In  favourable  subjects  one  may 
even  see  the  tracheal  bifurcation  with  the  openings  in  the 
bronchi  (r  b,  and  L  b.  Fig.  i),  the  right  being  the  most  visible. 
On  the  outskirts  of  the  larynx  proper,  but  quite  within  the  field 
of  the  laryngeal  mirror,  and  always  to  be  inspected,  are  the  hyoid 
fossae  (h  f,  Fig.  i),  one  on  each  side,  showing  through  the 
mucous  membrane  the  prominences  of  the  cornua  of  the  hyoid 
bone  (c  H,  Fig.  2).  These  cavities  are  of  considerable  surgical 
importance,  as  being  the  favourite  locality  for  foreign  bodies 
(Plate  VI.,  Fig.  54),  and  a  frequent  site  of  pharyngo-laryngeal 
cancer  (Plate  IX.,  Figs.  89  and  go). 

On  looking  into  the  larynx  by  means  of  the  laryngoscope  in  the 
manner  described  on  page  46,  et  seq.,  we  are  enabled  to  follow  the 
movements  of  the  parts  in  the  production  of  the  various  sounds. 
As  already  stated,  the  shape  of  the  rima  glottidis  during  ordinary 
quiet  respiration  is  somewhat  elliptical  (Fig.  VII., p.  15).  If,  however, 
the  utterance  of  a  sound  (phonation)  be  attempted,  the  vocal  cords 
are  seen  to  be  promptly  approximated,  and  the  superior  thyro- 
arytenoid ligaments  (ventricular  bands)  also  move  towards  the 
middle  line.  These  latter,  however,  never  meet  in  phonation,  and 
while  they  doubtless  influence  the  quality,  etc.,  of  the  voice,  they 
are  not  directly  concerned  in  voice  production.  As  soon  as  sound 
ceases  to  be  emitted  the  cords  quickly  return  to  their  previous 
position. 

There  is  a  position  of  the  cords  which  is  nearly  allied  to  that 
of  ordinary  respiration,  namely,  when  half-way  between  full 
adduction  and  complete  abduction.    This  has  been  termed  by 


68 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Ziemssen  the  'cadaveric'  position,  from  its  being  the  condition 
found  post  mortem.  It  might  also  be  called  the  position  of  repose. 
It  has  a  pathological  interest  in  connection  with  certain  disorders 
of  innervation  which  will  be  alluded  to  later  on. 

The  process  of  approximation  as  just  described  is  subject  to 
various  modifications.  For  instance,  in  *  aspirating,'  the  apposi- 
tion is  more  gradually  brought  about,  so  that  a  certain  quantity 
of  air  has  time  to  pass  through  before  the  cords  are  brought  into 
phonation  attitude.  On  the  other  hand,  the  closure  may  be 
absolute,  either  for  the  purpose  of  preventing  the  egress  of  air 
with  a  view  to  muscular  effort  or  as  preliminary  to  that  violent 
expulsive  opening  which  constitutes  '  cough.' 

For  vocal  purposes  the  cords  ought  to  come  together  and  be 
rendered  suitably  tense  at  the  same  time  as  the  current  of  air  is 
made  to  impinge  upon  them.  By  this  means  the  musical  note 
produced  is  clear  and  free  from  accessory  sounds.    On  termina- 


tion of  the  effort,  relaxation  and  abduction  of  the  cords  should 
follow  or  be  coincident  with  cessation  of  expiration. 

It  may  be  interesting  at  this  stage  to  review  briefly  the  changes 
in  the  position  of  the  cords  which  take  place  during  the  pro- 
duction of  the  different  registers  ;  a  register  being  understood  as 
consisting  of  a  series  of  tones  whicli  can  be  produced  by  the  same 
mechanism  (Behnke).  When  a  very  low  note  is  uttered,  the 
arytenoids  are  seen  (when  not  hidden  from  view  by  the  epiglottis, 
which  generally  curls  over  to  some  extent  during  the  emission  of 
very  low  notes)  to  be  closely  approximated  posteriorly,  leaving  an 
elliptical  opening  between  the  cords  (Fig.  XXXIV.).  The  ventri- 
cular bands  are  well  out  of  the  way,  and  allow  of  a  good  view  of 
the  cords  in  this  position. 

Somewhat  higher  in  the  scale  the  elliptical  opening  disappears, 
leaving  a  small  triangular  opening,  with  the  apex  pointing  for- 
ward, between  the  processus  vocales  ;  this,  in  its  turn,  is  no  longer 


Fig.  XXXIV.— Laryngeal  Image— Lower  Thick  Register. 


T  T.  Tongue. 

p  p.  Ventricular  bands. 

L.  Epiglottis. 


S  S.  Cartilages  of  Santorini. 

V  V.  Vocal  cords. 

\v  \v.  Cartilages  of  Wrisberg. 


THE  LARYNGOSCOPIC  IMAGE. 


visible  when,  or  before,  the  tone  is  raised  to  the  higher  A  note 
of  the  bass  clef  (Fig.  XXXVI.). 

These  notes  (up  to  the  lower  F  of  the  treble  clef)  are  all  pro- 
duced by  the  same  mechanism,  viz.,  by  vibrations  of  the  whole 
length,  breadth,  and  substance  of  the  vocal  cords,  which  through- 
out this  register  are  comparatively  thick.  Hence  this  series  of 
tone  is  spoken  of  as  the  '  thick  register.'  As  the  upper  hmit  is 
approached,  however,  the  epiglottis  straightens  itself  gradually, 
and  the  cords  are  evidently  subjected  to  great  tension.  This  is 
effected  chiefly  by  the  tilting  forward  of  the  thyroid  cartilage 
through  the  agency  of  the  crico-thyroid  muscles,  a  process  which 
can  be  felt  by  placing  the  finger  on  the  outside  of  the  throat. 

To  get  beyond  this  note  without  undue  strain  upon  the  cords  a 
different  mechanism  is  brought  into  play.  The  epiglottis  is 
raised  still  more,  the  upper  part  of  the  larynx  (the  vestibule)  is 


Fig.  XXXV.— Laryngeal  Image— Upper  Thick  Register. 

T  T.  Tongue.  s  s.  Cartilages  of  Santorini. 

p  P.  Ventricular  bands.  v  v.  Vocal  cords. 

L.  Epiglottis.  w  w.  Cartilages  of  Wrisberg. 

made  narrower  and  deeper,  and  the  ventricular  bands  are  brought 
nearer  to  one  another.  Moreover,  by  the  contraction  of  the 
outer  vertical  fibres  of  the  crico-thyroid  muscles  the  diameter  of 
the  inner  portion  of  the  thyro-arytenoid  muscles  is  diminished, 
and  the  vocal  cords  themselves  are  rendered  flatter,  thin«ner,  and 
quite  parallel.    This  series  has  been  called  the  '  thin  register.' 

The  thyroid  cartilage  resumes  to  a  great  extent  its  erect  posi- 
tion, and  the  pre-existing  strain  is  thus  relieved.  To  raise  the 
tone  the  same  tilting  forward  of  the  thyroid  again  comes  into 
play,  and  this  suffices  for  about  a  fifth  (to  the  middle  C  of  the  treble 
clef).  The  next  change  consists  in  the  formation  of  an  elliptical 
opening  (Fig.  XXXVII.)  between  the  cords  in  lieu  of  the  linear 
slit  which  characterized  the  preceding  register  (Fig.  XXXVI.), 
and  by  this  means  the  higher  F  may  be  reached. 

Finally,  in  order  to  continue  the  ascending  scale  to  the  end,  the 
posterior  parts  of  the  vocal  cords  are  held  firmly  together,  leaving 


70 


DISEASES  OF  THE  THROAT  AND  NOSE. 


only  a  small  oval  orifice  in  the  anterior  part  of  the  glottis,  which 
becomes  smaller  as  the  voice  ascends  (Fig.  XXXVIII.).  This 
series  has  been  called  the  '  small  register,'  and  is  only  to  be  seer 
in  the  case  of  females  and  of  boys. 


Fig.  XXXVL— LauVI\gkal  Lmage— Lowrr  Tpiin  Register. 


T  T.  Tongue. 

P  P.  Ventricular  bandf. 

L.  Epiglottis. 


s  s.  Cartilages  of  Santorini. 

V  V.  Vocal  cords. 

W  w.  Cartilages  of  Wrisberg. 


The  pitch  of  the  voice  is  thus  altered  (i)  by  the  degree  of 
tension  of  the  vocal  cords ;  (2)  by  their  thickness  and  width 
together  with  the  condition  (thick  or  thin,  tense  or  lax)  of  their 


Fig.  XXXVII.— Laryngeal  Image— Upper  Thin  Register. 

free  margins ;  (3)  by  the  shortening  of  the  vibrating  surface 
caused  by  the  close  juxtaposition  of  more  or  less  of  their  edges 
posteriorly ;  and,  finally,  (4)  by  variations  in  the  pressure  of  the 
expired  air. 


Fig.  XXXVIII.— Laryngeal  Image— Small  Register. 

It  must,  however,  be  borne  in  mind  that  the  positions  of  the 
soft  palate  and  uvula  are  also  changed  to  some  extent  according 
to  the  pitch  of  the  different  tones  ;  that  the  quality  of  the  voice  is 
materially  affected  in  this  region  by  the  degree  of  approximation 


THE  LARYNGOSCOPIC  IMAGE. 


71 


of  the  soft  palate  to  the  back  of  the  pharynx,  and  by  the  greater 
or  smaller  amount  of  nasal  escape  of  the  tone  consequent  there- 
upon. Fig.  XXXIX.  shows  the  palate  in  singing  F.  The  shape 
of  the  arch  2,  3,  2  should  be  remarked  in  order  to  compare  it 
with  Fig.  XL.,  which  shows  the  soft  palate  in  singing  the  A,  in 


Figs.  XXXIX.  and  XL.— The  Soft  Palate  in  Tonj:  Production, 
I.  Anterior  pill.irs  of  the  fauces.  2.  Posterior  pillars.  3.  Uvula. 


which  it  is  seen  to  be  much  higher  than  in  the  former.  The  next 
drawing  (Fig.  XLI.)  represer^ts  the  shape  of  the  faucial  arch 
in  singing  the  note  C  j  it  is  both  higher  and  narrower  than 


Figs.  XLI.  and  XLIL— The  Soft  Palate  in  Pure  Production  and  with 

Nasal  Tone. 

I.  Anterior  pillars  of  the  fauces.  2.  Posterior  pillars.  3.  Uvula. 


before,  while  the  uvula  has  contracted  so  much  as  to  have  almost 
completely  disappeared.  With  the  palate  so  raised  and  contracted 
the  tone  sung  is  pure  and  resonant. 

The  same  note  may  be  produced  with  the  palate  relaxed  and 
the  uvula  pendant  (Fig.  XLIL);  but  it  is  strongly  nasal  in  tone, 


72 


DISEASES  OF  THE  THROAT  AND  NOSE. 


and  is  greatly  wanting  in  resonance.  In  order  to  avoid  any  mis- 
apprehension as  to  the  meaning  of  terms  often  employed  as  inter- 
changeable, it  is  convenient  here  to  say  that  nasal  resonance  is 
intended  by  me  to  signify  the  normal  quality  of  tone  accompany- 
ing a  healthy  and  unimpeded  condition  of  the  naso-pharyngeal 
passages,  with  firm  closure  posteriorly  of  the  soft  palate  against 
the  back  of  the  pharynx.  Impaired  nasal  resonance,  or  deficient 
nasal  resonance,  is  produced  by  anything  that  blocks  these  pas- 
sages, as  polypi  of  the  nose,  adenoid  growths  in  the  vault  of  the 
pharynx,  or  thickening  of  the  naso-pharyngeal  mucous  membrane. 
The  term  nasal  tone  signifies  something  abnormal,  and  impHes 
escape  of  the  tone  through  the  nostrils,  due  to  imperfect  contrac- 
tion of  the  soft  palate  against  the  pharynx.  The  first  condition 
exists  in  the  *  dead  '  tone  of  a  person  speaking  with  a  cold  in  his 
head  ;  the  second  when  he  is  the  subject  of  a  relaxed  or  paretic 
soft  palate.  It  is  quite  possible  for  nasal  tone  to  exist  in  com- 
bination with  defective  nasal  resonance  ;  but  the  two  terms  repre- 
sent two  distinct  and  different  conditions,  and  need  never  be 
confounded  in  significance.  The  figures  here  inserted  are  tracings 
of  photographs  from  life,  and  the  whole  subject  has  been  treated  in 
detail  in  Voice,  Song,  and  Speech.  (See  also  British  Medical  Journal, 
October  27,  1883.) 

Auto-laryngoscopy. — A  great  deal  of  the  difficulty  which  is 
experienced  by  beginners  in  obtaining  a  good  view  of  the  larynx, 
is  attributable,  not  so  much  to  intrinsic  sensitiveness  of  the  parts 
to  be  examined,  as  to  a  want  of  dehcacy  and  management.  One 
of  the  best  ways  to  acquire  this  tacttis  eruditus  and  at  the  same 
time  to  become  familiar  with  the  appearances  of  a  (presumably) 
healthy  larynx,  consists  in  practising  a  systematic  investigation 
of  one's  own  throat.  No  additional  apparatus  is  required  beyond 
a  small  mirror,  which  is  so  placed  that  the  observer  is  enabled  to 
see  the  reflection  of  the  laryngoscopic  mirror  when  placed  in  situ 
in  his  own  throat.  A  very  ingenious  little  contrivance  was  in- 
vented for  this  purpose  by  the  late  Dr.  Foulis,  of  Glasgow,  con- 
sisting of  a  glass  globe  filled  with  water,  and  surmounted  by  a 
small  square  mirror  (Fig.  XLIII.). 

The  rays  from  a  candle  or  lamp  placed  behind  the  globe  are  by 
this  means  concentrated  into  the  open  mouth  of  the  observer, 
who  sits  in  front  of  it,  holding  the  laryngeal  mirror  at  the  back  of 
the  throat  in  the  manner  already  described.  He  will  thus  be  enabled 
to  see  the  resulting  image  in  the  larger  mirror  fixed  to  the  globe. 

Photo-laryngoscopy. — It  was  only  to  be  expected,  as  a  natural 
sequence  of  seeing  into  the  larynx,  that  attempts  should  be  made 
to  reproduce  its  image  by  means  of  photography,  and,  indeed, 


THE  LARYNGOSCOPIC  IMAGE. 


73 


Czermak,  who  appears  to  have  left  very  Httle  unattempted  in 
connection  with  the  subject,  succeeded,  upwards  of  twenty  years 
a^o,  in  obtaining  a  picture  which,  although  it  bears  on  the  face 
of  it  evidence  of  having  been  much  retouched,  is,  considering  the 
length  of  exposure  necessary  in  those  days,  a  very  wonderful  pro- 
duction. Our  own  process  consisted  in  concentrating  a  very 
powerful  electric  light  on  Mr.  Behnke's  pharynx,  he  being  so  seated 
that,  by  means  of  a  mirror  inserted  into  the  shutter,  he  could  see 
the  image  in  exactly  the  same  axis  as  it  would  be  in  the  camera. 


Fig.  XLIIL— The  Auto-Laryngoscope  of  Foulis. 


His  tongue  was  not  drawn  forward,  but  was  left  flat  in  the  mouth, 
so  as  not  to  distort  the  laryngeal  image.  When  we  were  agreed 
as  to  the  moment  for  photography  he  gave  the  signal,  and  an 
exposure  of  about  a  quarter  of  a  second  was  allowed.  As  a 
result,  we  obtained  some  marvellously  perfect  portraits,  which 
have  been  published  in  our  joint  work.  Voice,  Song,  and  Speech, 
and  were  exhibited  by  me,  on  magic-lantern  slides,  at  the  Liver- 
pool meeting  of  the  British  Medical  Association  in  1883,  on  two 
successive  days. 


74 


DISEASES  OF  THE  THROAT  AND  :>OSl\ 


We  were  exceptionally  fortunate,  first,  in  the  faciliiies  afforded 
us  at  the  Society  of  Arts  for  obtaining  a  magnificent  Siemens 
electric  light  of  10,000  candle  power  for  the  purpose  of  illumina- 
tion ;  and  secondly,  in  the  fact  that  Mr.  Behnke,  who  sat  for  the 
photographs,  had,  by  long  practice,  become  thoroughly  accus- 
tomed to  the  laryngeal  mirror,  and  had  also  acquired  the  art  of 
demonstrating  his  larynx  not  only  at  rest,  but  also  in  tone-pro- 
duction in  the  various  registers.  Dr.  French,  of  Brooklyn,  who 
for  many  years  had  been  working  at  the  subject  on  individuals 
totally  untrained,  has  succeeded,  after  much  patience,  in  producing 
very  good  photographs  on  a  minute  scale,  capable  of  enlargement 
and  reproduction.  Further  details  of  the  procedure  adopted  by 
French  will  be  found  in  the  Archives  of  Laryngology,  vol.  iv.,  p.  235. 
To  this  gentleman  belongs  the  honour  of  having  first  obtained  a 
photographic  image  of  portions  of  the  posterior  nares. 

Dr.  Stein,  of  Frankfort,  who  had  succeeded  in  photographing 
the  interior  of  the  eye  and  ear,  has  been  lately  devoting  himself  to 
photography  of  the  larynx,  using  for  that  purpose  a  special  photo- 
laryngoscope.  A  condensed  description  of  Dr.  Stein's  apparatus 
and  process  accompanies  the  plates  illustrative  thereof  on  the 
opposite  page  (Figs.  XLIV.  and  XLV.). 

By  the  kindness  of  Mr.  John  B.  Pearse,  an  enthusiastic 
amateur  singer,  and  the  aid  of  a  professional  photographer,  I 
have  been  able  to  share  in  experiments  with  Stein's  apparatus, 
but  we  have  not  succeeded  in  taking  pictures  so  good  as  those  of 
French,  and  it  is  indeed  difficult  to  believe  that  any  useful  portraits 
of  the  larynx  could  ever  be  obtained  by  its  means.  However, 
while  I  fully  recognise  that  my  own  facilities  as  a  draughtsman 
may  prejudice  me  in  favour  of  the  pencil  over  the  camera,  I 
apprehend  it  will  be  generally  conceded  that  laryngo-photography, 
interesting  though  it  be,  is,  at  any  rate  at  present,  little  more 
than  a  scientific  amusement.  It  is  suggested  that  the  process  is 
likely  to  be  of  service  in  verifying  improvements,  or  the  reverse, 
of  laryngeal  disease  under  treatment ;  but  functional  evidence:- 
will  to  the  majority  supply  more  conclusive  proofs. 


CHAPTER  V. 


EHINOSCOPY,  OR  EXAMINATION  OF  THE  NASAL 
PASSAGES.— THE  RHINOSCOPIC  IMAGE. 

Rhinoscopy,  or  investigation  of  the  upper  pharynx  and  the  interior 
of  the  nose,  has  become  inseparably  connected  with  laryngoscopy, 
not  only  because  of  the  similarity  in  the  methods  of  investigation, 
but  for  anatomical  and  pathological  reasons.  For  experience  has 
taught  us  that  in  many  diseases  of  the  throat  we  must  look  to 
previous  or  simultaneous  affections  of  the  mucous  membrane  and 
submucous  tissues  of  the  nose  and  pharynx  for  their  etiological 
elements.  As  a  natural  result,  the  employment  of  the  rhinoscopic 
mirror  and  speculum  has  led  to  a  greatly  extended  study  and  a 
consequently  more  perfect  knowledge  of  the  various  morbid  pro- 
cesses in  the  regions  so  brought  under  observation.  The  increased 
visual  command  thus  gained  has  also  led  to  greater  accuracy  and 
many  improvements  in  the  direction  of  topical  remedies  to  these 
passages. 

Anterior  Rhinoscopy. — Much  information  as  to  the  condition 
of  the  nasal  cavity  may  be  gained  by  careful  inspection  from  the 
nostrils,  although  the  comparatively  small  size  of  the  aperture 
of  necessity  greatly  limits  the  field  of  observation.  Light,  either 
direct  or  reflected,  is  again  called  into  requisition,  and  the  view 
of  the  nostrils  facilitated  by  the  use  of  a  suitable  speculum  or 
dilator.  In  nasal — and,  indeed,  in  all — instruments  the  great 
object  should  be  to  have  them  as  simple  as  possible;  but  this  is 
by  no  means  universally  borne  in  mind  b}'  instrument-makers  and 
surgeon-inventors. 

Duplay's  speculum  (Fig.  XLVI.)  was  one  of  the  first  intro- 
duced, but  is  of  rather  cumbersome  construction,  and  heavy.  It 
is  moreover  not  self- retaining.  Frankel's  speculum  (Fig.  XLVI  I.), 
until  recently  in  general  use,  is  only  moderately  serviceable  from 
the  fact  that  the  small  space  brought  into  view  is  still  further 
narrowed  by  prolapse  through  the  fenestrations  of  the  tissues 


EXAMINATION  OF  THE  NASAL  PASSAGES,  77 

attempted  to  be  dilated.  The  same  objection  applies  to  Cohen's 
hair-pin  speculum,  useful  as  it  is  for  cases  of  emergency;  and  to  the 
instrument  of  similar  construction  suggested  by  Baber,  which  is 
made  self-retaining  by  a  rather  terrifying  arrangement  of  bands 


Fig.  XLVL— Duplay's  Nasai.  Speculum. 


and  buckles.  Many  years  ago  I  had  a  Frankel's  speculum  made 
with  the  fenestrations  filled  up,  and  they  are  now  sold  in  that  form. 
A  further  improvement  has  been  effected  by  a  screw,  fixing  the 
blades  at  the  desired  point  of  dilatation  ;  but  the  instrument  is  at 


Fig.  XLVII.-^Frankel's  Nasal  SpeculuxM. 

best  an  inconvenient  one,  from  the  peculiar  curve  of  its  dilating 
blades,  as  also  from  their  undue  length  and  narrowness.  This 
last  defect,  that  of  narrowness,  is  an  objection  also  to  Shurley's 
speculum,  an  otherwise  good  instrument  as  far  as  the  shape  and 


Fig.  XLVIII. — Thudichum's  Nasal  Speculum. 


length  of  the  blades  are  concerned.  The  principle  of  Thudi- 
chum's instrument  is  sound,  except  that  the  spring  is  so 
strong  as  generally  to  cause  great  discomfort,  and  in  some 
cases  actual  pain,  to  the  patient  I  formerly  used  the  trivalve 
nasal  speculum  of  Elsberg,  to  which  was  added,  at  my  sug- 


78 


DISEASES  OF  THE  THROAT  AND  NOSE. 


gestion,  a  rack  to  keep  it  open  at  any  desired  width.  The 
instrument  (Fig.  L.)  which  I  have  now  employed  for  the  last  ten 
years,  to  the  exclusion  of  all  others,  was  suggested  in  the  first 
instance  by  that  of  Maunder  for  straightening  the  septum.  The 
blades  are  of  the  same  shape  as  those  in  Thudichum's  speculum, 
but  are  made  of  ivory  instead  of  metal,  so  as  to  be  more  readily 
serviceable  when  the  cautery  is  used.    The  bridge  connecting  the 


Fig.  XLIX. — Elsberg's  Nasal  Speculum,  with  Autiior'o  Rack  Movement 
(Half  Measurements). 

blades  is  shortened  by  a  telescopic  arrangement,  and  being  shghtly 
resilient,  allows  of  a  delicate  adjustment  of  the  spring-force  suffi- 
cient for  self-retention,  but  not  enough  to  cause  pain  or  even  dis- 
comfort. I  was  recently  shown  an  *  improvement '  of  my  instru- 
ment by  a  maker,  which  was  of  such  a  nature  as  to  have  improved 
away  every  feature  of  good  that  I  venture  to  think  it  possesses. 


The  blades  were  of  metal,  the  bridge  was  rigid,  and  the  amount 
of  expansion  was  regulated  by  a  screw.  I  have  found  little  benefit 
from  the  use  of  long  tubes  to  be  introduced  into  the  nostrils  as 
suggested  by  Zaufal,  the  area  of  inspection  being  too  limited,  and 
the  view  gained  being  equally  attainable  in  most  cases  by  posterior 
rhinoscopy.  Moreover,  their  introduction  is  generally  attended 
by  both  pain  and  haemorrhage. 


EXAMINATION  OF  THE  NASAL  PASSAGES. 


79 


The  followin*^  are  the  necessary  steps  to  be  taken  for  anterior 
examination  of  the  nose.  The  patient  being  seated,  with  the 
head  thrown  back  and  rested  on  the  back  of  the  chair,  the  observer, 
who  sits  in  front  of  him,  gently  introduces  the  dilator  and  fixes  it  in 
position.  The  light  is  then  focussed  on  the  nostril  to  be  examined, 
the  entrance  to  which  will  then  be  seen  as  an  irregular  oblong 
cavity,  and  on  dilatation  the  contents  of  the  anterior  nares  come 
into  view. 

Before  describing  them  it  may  be  noted  that  for  anterior 
rhinoscopy  to  be  serviceable  it  is  essential  that  the  operator 
should  be  thoroughly  acquainted  with  the  anatomical  relation  of 
the  parts  he  wishes  to  see ;  but  as,  with  the  best  of  specula,  the 
field  of  vision  is  limited,  he  is  obliged  to  frequently  alter  its  axis 
in  the  direction  of  the  different  choange  ;  and  no  observation  can 
be  considered  complete  unless  the  examination  is  thus  conducted. 
The  planes  of  the  different  parts  to  be  inspected  are  so  variable, 
however,  that  it  is  quite  impossible  by  any  sort  of  figure  to  give  a 
useful  and  clear  impression  of  what  one  desires  to  convey  to 
others,  however  serviceable  such  an  outline  may  be  to  the  ob- 
server for  his  own  purposes  of  reference.  There  are  a  large 
number  of  variations,  especially  of  the  septum  and  inferior  turbi- 
nated body,  as  well  as  those  depending  on  the  degree  of  patency 
of  the  nostril  itself,  which  very  seriously  alter  the  image,  but 
which  are  by  no  means  pathological,  just  as  there  are  changes  in 
the  external  configuration  of  the  nose.  For  all  these  reasons,, 
and  after  full  deliberation,  I  have  decided  not  to  give  any  outHne 
conventional  figures  of  the  anterior  nares  as  first  adopted  by 
Seiler  in  1879,  and  such  as  I  have  so  long  recommended  for  the 
graphic  record  of  pathological  changes  in  the  fauces,  larynx,  and 
posterior  nares. 

The  Anterior  Rhinoscopic  Image. — The  first  object  to  notice 
is  the  median  septum,  which  separates  the  nostril  from  its  fellow 
and  is  often  deflected  to  one  side  or  the  other.  On  the  outer  side 
the  inferior  turbinated  body  is  visible,  and  forms  the  roof  of  the 
inferior  meatus  of  the  nose,  at  the  far  end  of  which,  in  favourable 
cases,  may  be  seen  the  movement  of  the  palatal  muscles  in  swal- 
lowing. By  altering  the  axis  of  vision  the  middle  and  even  a 
portion  of  the  superior  turbinated  bones  may  be  perceived. 

The  septum  so  frequently  deviates  from  the  mesial  line  that 
unless  there  is  difficulty  in  nasal  respiration,  not  accounted  for  by 
other  circumistances,  no  clinical  importance  need  be  attached  to 
the  fact.  Baber  has  the  merit  of  first  drawing  attention  to  the 
importance  of  the  itibercle  of  the  septum,  the  varying  forms  and 


So  DISEASES  OF  THE  THROAT  AND  NOSE. 


position  of  which  may  greatly  influence  the  appearance  of  the 
anterior  rhinoscopic  image;  but  it  may  be  mentioned  that  its 
actual  existence  is  by  no  means  uniform.  On  the  other  hand,  not 
only  at  the  situation  of  the  tubercle,  but  along  the  lines  of  suture, 
distinct  osteo-cartilaginous  spurs  are  not  infrequently  met  with. 
Even  when  these  do  not  interfere  with  the  respiratory  function  of 
the  nostrils,  they  may  bear  causal  relation  to  certain  reflex 
neuroses  (see  Chapters  XXIV.  and  XXV.).  The  inferior  turbinated 
body  is  the  part  which  next  claims  our  attention,  and  varies  greatly 
in  size  and  colour  within  the  limits  of  health.  Its  mucous  cover- 
ing is  soft  and  smooth,  and  when  congested  or  swollen  is  sometimes 
mistaken  for  a  polypus.  At  the  lower  border  of  the  inferior  turbinal 
may  be  seen  the  inferior  meatus.  The  middle  turbinal  lies  far  higher 
up,  and  for  its  inspection  requires  that  the  head  of  the  patient  be  set 
further  back.  The  portions  seen  on  anterior  examination  are  the 
anterior  and  inferior  surfaces.  At  the  outer  edge  is  the  middle 
meatus,  on  the  inner  the  olfactory  slit.  The  superior  turbinal  is  but 
very  rarely  visible  by  anterior  rhinoscopy.  The  coloration  of  the 
parts  seen  from  the  front  differs  somewhat  from  that  of  the  same 
structures  as  viewed  by  posterior  rhinoscopy.  The  inferior  tur- 
binated body  is  of  a  vivid  red ;  the  septum  is  also  distinctly  red, 
but  of  not  so  strong  a  hue,  while  the  middle  turbinated  body  and 
the  olfactory  area,  not  often  seen,  are  of  a  still  paler  tint. 

Posterior  Rhinoscopy  is  to  all  intents  and  purposes  the  same 
process  as  laryngoscopy,  except  that  the  laryngeal  mirror  is  turned 
upwards  to  obtain  a  view  of  the  posterior  nares,  and  is,  when  used 
for  this  purpose,  called  the  rhinal  mirror.  Rhinoscopy  is  a  more 
difficult  process  than  laryngoscopy,  inasmuch  as  %tnore  causes  of 
failure,  due  to  natural  conformation  of  the  parts,  enter  into  con- 
sideration, and  prevent  a  satisfactory  rhinoscopic  image  from 
being  obtained.    Of  these  the  following  are  the  principal : 

a.  The  arching  up  of  the  dorsum  of  the  tongue. 

/3,  Irritability  of  pillars  of  fauces,  and  of  posterior  wrdl  of  the 
pharynx. 

7.  Enlarged  tonsils  and  uvula. 

8.  Insufficient  distance  between  the  uvula  and  posterior  wall  of 
the  pharynx. 

In  laryngoscopic  examination,  as  has  been  pointed  out,  it  is 
not  necessary  to  touch  the  pharynx  or  fauces,  but  in  using  the 
rhinal  mirror  it  is  often  impossible  to  avoid  doing  so.  The 
third  difficulty  is  the  greatest,  and  to  overcome  it  many  instru- 
ments  have  been  suggested  to  draw  the  uvula  forward,  and  so  to 
increase  the  area  open  to  inspection;  but  they  have  not  com. 
mended  themselves  to  me,  and  are  never  employed  either  by  my 


EXAMINATION  OF  THE  NASAL  PASSAGES. 


8i 


colleagues  or  myself.  As  a  matter  of  experience,  I  have  long 
come  to  the  conclusion  that,  while  ease  and  completeness  of  post- 
rhinal  examination  depend  almost  entirely  on  the  amount  of  space 
at  command  between  uvula  and  post-pharyngeal  wall,  so  also 
does  this  condition  favour  disease  in  the  region  under  considera- 


FiG.  LI.— Curve  of  Shank  of  Mirror,  and  Position  of  Hand 


NECESSARY  FOR  RHINOSCOPY. 

tion — that  is  to  say,  the  wider  the  distance  between  soft  palate 
and  pharynx,  the  more  surely  one  may  expect,  on  examination,  to 
find  post-nasal  trouble.  This  little  fact  is  one  of  some  consolation 
where  a  rhinoscopic  examination  is  unsatisfactory  on  account  of 
the  contrary  relation  of  these  parts. 

The  steps  necessary  to  take  in  making  a  rhinoscopic  inspection 


Fig,  IJI. — Frankel's  Rhinoscopic  Mirror  (One-thikd  Measurements). 

are  exactly  the  same  as  for  the  laryngoscopic  up  to  No.  6  (see 
page  47) ;  but  the  mirror  used  must  be  of  the  smallest  size  in 
Fig-.  XXIV.,  and  should  be  curved  so  as  to  take  the  shape  of  the 
the  floor  of  the  mouth  (Fig.  LI.).  My  own  examinations  have 
always  been  made  with  the  small-sized  laryngeal  mirror  suitably 

6 


82 


DISEASES  OF  THE  THROAT  AND  NOSE. 


curved,  as  shown  in  this  illustration.  The  instrument  known 
as  Frankel's  (Fig.  LII.),  by  means  of  a  sliding  lever  enables  the 
surgeon  to  vary  the  angle  of  the  mirror  by  a  simple  movement  of 
his  thumb.  Though  in  general  use  by  many  surgeons,  it  has  not 
been  found  necessary  for  employment  in  ordinary  examinations  in 
my  own  practice  ;  but  it  will  be  found  convenient  in  those  cases  in 
which  the  space  between  the  soft  palate  and  back  of  the  pharynx 
is  unusually  narrow. 

As  in  inspection  of  the  fauces,  so  also  in  rhinoscopy,  some  form 
of  tongue-depressor  is  often  indispensable ;  and  although  Stoerck 


Fig.  LIII. —Section  showing  Position  of  Mirror  and  Patient's  Head 
FOR  obtaining  A  Riiixoscopic  Image. 

and  Voltolini  have  both  devised  an  instrument  which  combines 
in  itself  mirror  and  depressor,  they  have  acknowledged  that 
nothing  is  gained  by  such  an  arrangement,  except  that  it  leaves 
one  hand  of  the  examiner  free ;  while  it  possesses  the  decided 
disadvantage  of  limiting  the  movements  of  the  mirror  so  essential 
to  successful  rhinoscopic  observations.  For  this  purpose  I  prefer 
a  Frankel's  or  Hill's  tongue-depressor  (Fig.  XXVIII.). 

As  before  stated,  the  patient  is  placed  as  for  laryngoscopic 


EXAMINATION  OF  THE  NASAL  PASSAGES. 


83 


examination,  except  that  the  head  is  inclined  sHghtly  forward 
instead  of  backward.  This  procedure  is  important  for  two 
reasons  ;  first,  because  it  brings  the  more  anterior  portions  of  the 
nares  in  a  direct  hne  with  the  reflected  hght ;  and,  secondly, 
because  such  a  position  allows  the  pendulous  portion  of  the  soft 
palate  to  fall  away  from  the  posterior  wall  of  the  pharynx.  Carl 
Michel,  of  Cologne,  also  advises  that  before  opening  the  mouth 
the  patient  should  place  it  in  the  position  of  a  broad  grin,  as  in 
this  situation  the  soft  palate  is  more  pendulous.  Experience 
justifies  me  in  endorsing  this  recommendation.  The  tongue, 
unless  under  control  of  the  patient,  is  now  depressed  gently  but 
firmly,  care  being  taken  not  to  use  more  force  than  is  necessary. 
The  mirror  is  introduced  with  especial  care  not  to  touch  either 
tongue,  palate,  or  wall  of  the  pharynx  (this  is  not  difficult),  the 
body  of  the  mirror  being  sidled  beneath  the  arch  of  the  palate, 
and  then  turned  into  proper  position,  with  its  face  looking  upwards 
and  forwards,  by  placing  its  handle  parallel  with  the  long  axis  of 
the  tongue.  The  tendency  of  the  velum  to  contract  and  cut  off 
the  light  from  the  mirror  is  best  counteracted  by  directing  the 
patient  to  breathe  slowly  through  the  nose,  and  at  intervals  to 
emit  a  long-drawn  groan,  both  of  which  proceedings  cause  the 
whole  to  relax  and  remain  flaccid. 

There  are,  nevertheless,  cases  where,  from  various  causes,  the 
distance  between  the  soft  palate  and  the  posterior  wall  of  the 
pharynx  is  too  smafl  to  admit  of  ordinary  rhinoscopy,  and  pos- 
sibly also  some  in  which  it  is  desirable  to  have  increased  space 
for  the  removal  of  growths,  etc.  In  such  contingency  the 
following  measure  has  been  recommended.  With  a  Bellocq's 
canula,  pass  a  strip  of  small-sized  soft  rubber  tubing  (such  as  is 
used  for  drainage  in  small  wounds)  through  the  inferior  nasal 
passages,  and  drawing  their  ends  through  the  mouth,  tie  them  to 
the  portion  left  projecting  from  the  nostrils.  By  this  means  the 
velum  palati  is  folded  upon  and  held  close  in  contact  with  the 
roof  of  the  mouth,  and  cannot  interfere  with  the  reflection  of 
light  into  the  posterior  nares.  This  proceeding  is  said  to  be  only 
at  first  attended  with  a  few  spasms  of  sneezing  and  retching, 
which,  however,  soon  pass  oft^,  and  the  bands  may  then  be  left  m 
situ  for  ten  or  fifteen  minutes  without  occasioning  pain  or  exces- 
sive discomfort.  I  have,  however,  rarely  found  it  needful  to  resort 
to  such  elaborate  measures  ;  but  when  adventitious  aid  is  neces- 
sary, and  also  in  some  operations  in  the  post-nasal  space,  the 
palate-hook  of  White,  of  Richmond,  U.S.A.,  is  of  the  greatest 
service,  and  can  be  employed  without  discomfort  if  the  soft  palate 
has  been  previously  cocainized. 


84  DISEASES  OF  THE  THROAT  AND  NOSE. 

With  a  view  of  lessening  the  sensitiveness  of  the  parts,  I  have 
lately,  in  common  with  most  other  practitioners,  been  in  the  habit 
of  applying-  to  the  velum  and  fauces  a  five  or  ten  per  cent,  solution 
of  hydrochlorate  of  cocaine.  This  subdues  the  reflex  excitability 
of  the  mucous  membrane,  and  diminishes  the  discomfort  attend- 
ing these  kinds  of  manipulations. 

Digital  Examination  of  the  posterior  nostrils  is  of  the  highest 
value,  and  should  never  be  neglected  in  the  case  of  children,  as 
it  often  affords  most  valuable  information,  especially  when  the 
result  of  a  visual  inspection  has  been  unsatisfactory.  It  is,  how- 
ever, necessary  for  this  purpose  that  the  observer  should  thoroughly 
know  the  relative  normal  position  and  sensation  to  touch  of  the 
parts.  The  procedure  should,  of  course,  only  be  resorted  to  after 
the  mirror  examination,  which  would  otherwise  be  rendered  im- 
possible ;  and  one  of  the  finger-guards  already  described  (p.  57) 
is  desirable.  The  process  is  disagreeable  rather  than  painful ;  it 
is  sometimes  followed  by  more  or  less  haemorrhage,  which  is  not, 
however,  of  importance,  except  as  a  diagnostic  indication. 

Preliminary  to  making  the  examination,  especially  in  children, 
the  head,  with  the  exception  of  the  face,  should  be  enveloped  in  a 
large  towel,  the  two  ends  of  which  may  be  made  to  meet,  and  if 
held  firmly  by  a  nurse  or  assistant,  restrain  movement  of  the  arms 
as  effectively  as  would  a  straight  jacket.  The  surgeon  should 
then  place  the  head  so  covered  under  his  left  arm,  steadying  it 
with  the  corresponding  hand,  one  finger  of  which  presses  in  the 
patient's  cheek  so  as  to  act  as  a  gag ;  then  deftly  introducing  the 
right  index-finger  as  far  back  in  the  throat  as  the  posterior 
pharyngeal  wall,  he  should  turn  it  upwards  behind  the  uvula. 
Spasm  is  soon  overcome,  and  then,  zcith  the  septum  as  a  guide,  the 
whole  of  the  space  between  the  Eustachian  opening  and  the  vault 
of  the  pharynx  can  be  explored.  It  should  be  smooth  and  free 
from  prominences.  The  inferior  surfaces  of  the  turbinated  bodies 
can  also  be  examined  in  this  way  for  evidences  of  the  presence  of 
h3^pertrophies  and  new  growths.  Care  should  be  taken  not  to 
mistake  the  cartilaginous  lip  of  the  Eustachian  orifice  (Fig.  LIV., 
15)  for  a  morbid  induration. 

Some  writers  on  this  subject  recommend  the  use  of  a  nasal 
probe  in  order  to  determine  the  mobility,  etc.,  of  the  parts  brought 
into  view,  but  this  practice  cannot  be  recommended  for  general 
adoption  any  more  than  the  use  of  a  similar  instrument  in  the 
larynX;  unless  the  membrane  has  been  previously  anaesthetized, 


EXAMINATION  OF  THE  NASAL  PASSAGES. 


since  the  irritation  and  (it  may  be)  haemorrhage  so  caused  is  apt  to 
set  up  reflex  movements  which  materially  impede  and  sometimes 
altogether  prevent  any  further  examination.  To  obtain  local 
insensibility  I  employ  small  pledgets  of  cotton-wool  soaked  in  a  20 
per  cent,  solution  of  cocaine,  which,  being  placed  in  the  nostril, 
are  left  there  for  at  least  fifteen  minutes.  The  nasal  probe,  although 
to  be  used  with  caution,  is  of  great  value  in  determining  consist- 
ence and  attachments  of  new  growths,  the  existence  of  necrosis, 
the  presence  of  foreign  bodies,  etc. 

The  Posterior  Rhinoscopic  Image  (Figs.  LIV.  and  LV.,  and 
also  Fig.  38,  Plate  V.,  at  end  of  the  book). — A  view  of  the  post- 
nasal passage  is  not  only  more  difficult  to  obtain,  but  is  less  easy 


Fig.  LIV, — The  Posterior  Rhinoscopic  Image. 


1.  Septum. 

2.  Middle  turbinated  bone. 

3.  Inferior  turbinated  bone. 

4.  Superior  turbinated  bone. 

5.  Superior  meatus. 

6.  Middle  meatus. 

7.  Inferior  meatus, 

8.  Main  passage  of  nostrils. 


17- 


9.  Vault  of  pharynx  and  pharyngeal  tonsil. 

ID.  Cushion  of  €oft  palate. 

11.  Posterior  surface  of  uvula. 

12.  Ridge  formed  by  levator  palati. 

13.  Salpingo-pharyngeal  fold. 

14.  Salpingo-palatine  fold. 

15.  Eustachian  prominence  or  cushion. 

16.  Fossa  of  Rosemiiller. 
Eustachian  orifice. 


for  the  beginner  to  realize  in  detail,  since  the  small  amount  visible 
in  the  mirror  at  first  sight,  and  the  different  angles  at  which  the 
mirror  must  be  turned,  may  sometimes  create  a  difficulty  in 
identifying  what  is  seen.  It  becomes  necessary,  therefore,  to 
shift  the  mirror,  and  only  practice  will  enable  the  observer  to 
compare  the  various  views,  so  as  to  form  an  accurate  judgment 
of  the  condition  of  the  entire  cavity.  For  these  reasons  the 
depicted  image  must  always  be  of  composite  character.  Com- 
parison of  the  rhinoscopic  image  in  Fig.  LIV.  with  that  of  the 
posterior  nares,  as  seen  on  dissection  in  Fig.  LV.,  will  greatly 
facihtate  appreciation  of  the  various  structures  and  of  their 
situations. 


86 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  septum  (i)  divides  the  posterior  nares  into  two  symmetrical 
halves,  and  this  line  is  a  useful  guide  to  the  relative  positions  of 
the  various  parts.  It  is  thin  and  pale  in  colour,  the  mucous 
membrane  being  firmly  attached,  and  showing  the  bone  under- 
neath. The  posterior  nares,  two  oval  spaces,  bounded  by  the 
vomer  or  septum  on  one  side,  and  the  external  wall  of  the  nostril 
on  the  other,  will  now  be  observed,  and  in  their  respective  posi- 
tions the  middle  (2),  the  inferior  (3),  and  the  superior  (4)  turbinated 
bones,  the  first-named  being  that  which  is  most  seen,  the  other 


Fig.  LV. 


-View  of  the  Posterior 
from  behind 


B.  Basilar  process. 
P.  Pharynx. 
I.  Septum. 


Middle  turbinated  bone. 
Inferior  turbinated  bone. 
Superior  turbinated  bone. 
Superior  meatus. 
Middle  meatus. 
Inferior  meatus. 
Main  passage  of  nostrils. 


Nares,  the  Pharynx  being  laid  open 
(after  Luschka). 

9.  Vault  of  the  pharynx  and  Luschka's  tonsil. 

10.  Cushion  of  the  soft  palate. 

11.  Posterior  surface  of  uvula. 

.  12,  Ridge  formed  by  levator  palati  (L.  P.). 

13.  Salpingo-pharyngeal  fold. 

14.  Salpingo-palatine  fold. 

15.  Eustachian  prominence  or  cushion. 

16.  Eustachian  tube,  closed  on  the  left  and 

laid  open  on  the  right  side. 

17.  Eustachian  orifice. 


two  being  only  partially  visible.  There  may  be  considerable 
divergence  in  symmetry  in  these  structures,  which  is  not  always 
due  to  abnormiality.  Between  the  various  spongy  bones  may  be 
seen  the  three  meatus— superior  (5),  middle  (6),  and  inferior  (7)— 
and  the  space  between  the  inner  boundary  and  the  free  edge 
of  the  septum  is  the  open  passage  of  the  nostrils  (8).  At  the 
upper  part  of  the  image,  above  the  vomer  and  the  boundary  of 
the  nasal  orifice,  can  be  seen  the  vault  of  the  pharynx  (9),  with 
the  masses  of  adenoid  tissue  constitutin/r  the  pharyngeal  tonsils 


EXAMINATION  OF  THE  NASAL  PASSAGES. 


87 


of  Santorini  and  Luschka.  The  lower  boundary  of  the  posterior, 
and  a  portion  of  the  inferior,  turbinated  bone  is  cut  off  from  view 
by  the  posterior  wall  of  the  velum  (lo),  which,  as  well  as  the 
posterior  surface  of  the  uvula  (ii),  is  seen  at  a  still  lower  level, 
the  colour  of  these  parts  being  a  florid  red.  At  the  lower  portion, 
and  external  to  the  nasal  fossa,  slightly  below  the  level  of  the 
middle  meatus  (12),  is  seen  a  cup-like  depression  of  oval  shape, 
and  with  elevated  ridges  :  this  is  the  orifice  of  the  Eustachian 
tube  (17).  The  inner  ridge  is  formed  by  the  salpingo-palatine 
fold  (14),  the  outer  by  the  salpingo-pharyngeal  fold  (13) ;  while 
below  is  seen  the  elevation  formed  by  the  levator  palati  muscle. 
The  upper  margin  of  the  Eustachian  tube,  as  seen  in  the  mirror 
(in  reality  the  posterior  border),  is  formed  by  its  posterior  car- 
tilaginous wall,  which  is  very  prominent ;  it  is  known  as  the 
Eustachian  cushion  (15),  and  it  forms  the  anterior  boundary  of  the 
fossa  of  Rosenmtiller  (16).  This  last-named  depression  lies  above 
and  externally  in  the  image,  posteriorly,  in  fact,  to  the  tube  itself. 
It  is  of  clinical  importance  as  being  very  commonly  mistaken 
for  the  tubal  opening  itself  by  those  unaccustomed  to  pass  the 
Eustachian  catheter. 

The  mucous  membrane  of  the  naso-pharynx  is,  in  the  normal 
state,  generally  of  brighter  hue  than  that  of  the  lower  pharynx — 
an  important  point  to  remember  in  practice.  The  septum  and 
Eustachian  orifices  are  pale,  and  the  turbinated  bodies  of  a  pinkish- 
grey.  The  lower  turbinated  bone  is  paler  in  tint  than  the  others, 
and  of  more  uneven,  sponge-like  surface — a  detail  which  has  been 
overlooked  in  most  coloured  illustrations,  and  is  unfortunately  not 
well  represented  in  my  own.  The  wood-engraving  which  I  have 
re-drawn  for  this  edition  is  in  this  and  most  respects  a  more 
faithful  representation.  The  roof  of  the  pharynx  is  redder  than 
the  other  contents  of  the  nasal  passages  just  described,  and  of 
more  or  less  uneven  surface,  owing  to  the  presence  of  the  adenoid 
tissue  already  mentionedc  The  pharyngeal  bursa  of  Luschka, 
which  has  been  invested  with  so  much  importance  by  Tornwaldt 
(Chapter  XXIV.),  can  sometimes  be  recognised,  on  the  posterior 
wall,  by  the  presence  of  mucus  at  its  orifice.  Its  situation  and 
indeed  its  existence  are  both  variable. 


CHAPTER  VI. 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES. 

In  taking  a  case  of  throat  disease,  after  the  usual  questions  of 
identity,  predisposing  and  exciting  causes,  it  will  be  well,  in  order 
to  simplify  matters,  to  classify  the  symptoms  under  the  following 
headings  : 

(A)  Functional  or  Subjective,  including  impairment  of  the 
functions  of  voice,  respiration,  deglutition,  and,  in  many  pharyngeal 
and  nasal  diseases,  of  the  special  senses  of  hearing,  smell,  and 
taste ;  the  phenomena  of  cough,  and  the  amount  and  character 
of  expectoration  and  of  mucous  and  salivary  secretion.  Pain, 
irrespective  of  exercise  of  function,  and  nervous  phenomena,  such 
as  that  known  by  the  term  globus  hysterims,  may  be  also  considered 
under  this  heading. 

(B)  Physical  or  Objective,  embracing  all  the  appearances 
viewed  by  the  observer,  within  the  mouth  and  the  passages  of  the 
throat  and  larynx,  special  reference  being  given  to  alterations  in 
colour,  form,  position,  and  mobility. 

(C)  Miscellaneous  and  Commemorative,  which  include  those 
presented  on  external  examination,  as  well  as  those  which  affect 
the  constitution  generally.  Here  may  also  be  included  examina- 
tion of  the  chest,  of  the  auditory  apparatus,  and  of  the  nasal 
passages. 

The  following  tabulated  list  of  symptoms  will,  it  is  thought, 
facilitate  reference  in  future  ;  each  of  the  various  classes  of 
symptoms  can  then  be  considered  in  detail.  The  arrangement  is 
that  which  I  devised  for  use  at  the  Central  Throat  and  Ear 
Hospital  for  the  taking  of  cases  requiring  detailed  notes.  An 
abridged  form  is  employed  for  those  of  less  interest,  and  the 
various  appearances  on  visual  inspection  are  noticed  as  occasion 
may  require  on  one  of  the  outline  forms  (Fig.  LVL),  which  were 
first  introduced  at  that  institution,  and  are  kept  in  books  with 
adhesive  backs  for  application  to  the  case  papers. 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES.  89 


[Books  of  these  forms,  for  taking  either  throat  or  aural  cases, 
are  published  by  Messrs.  Bailliere,  Tindall,  and  Cox.] 

A.  Functional  or  Subjective  Symptoms: 


[,  Voice  may  be 


'Modified  in  tone,  power,  and  endurancii. 
Hoarse,  husky,  thick,  guttural  or  nasal. 
Aphonic,  or  polyphonic. 
Jerky. 

Shrill,  or  squeaky. 

^Attended  with  pain  or  fatigue  (mogiphonia  or  odyphonia). 


[monary. 


(Articulation  may  be  impaired  irrespective  of  phonetic  quality.) 

=.  Respiration  "''y/ cf„^^J  ™,'''"''°"'lM''y  be  painful. 

be  embarrassed  \ 5° "g^^ j  Embarrassment  may  be  laryngeal  or  pul- 

Note — and  if  necessary  test  with  Spirometer — vital  capacity,  and  observe  whether 
respiratory  act  is  full  and  abdominal,  lateral  or  costal,  or  exaggerated  to  clavicular  eleva- 
tion. 

Irritable.        COn  rising. 
Hacking.         After  exertion. 
Painful.         <  After  meals. 
Paroxysmal.      On  change  of 
, Continuous.    L  temperature. 


3.  Cough  may  be 


With  or  without  expectoration  or 
hemorrhage. 


Its  phonetic  character  may  vary  and  be 


^  Hoarse. 

Barking. 

Metallic. 

Stridulous. 
^Aphonic. 


4.  Deglutition  may  be  - 


Difficult 
{Dysphagia). 

Painful 
{Odynphagia). 
Impossible 
{Aphagia). 


Varying  with  consistence  and  temperature 
of  food. 


Nasal  Symptoms  : — 

5.  Nasal  respiration  may  be  impaired,  or  altogether  obstructed,  in  one  or  both  nostrilfi. 
N.B.  Dryness  of  throat  and  mouth  on  rising  is  an  almost  invariable  symptom  of 

mouth-breathing  due  to  nasal  stenosis.  Inquire  as  to  snoring.  Examine  odour  of  air 
expired  through  the  nose. 

r  IiTipaired, 

6,  Senses  of  smell  and  of  taste  may  be  J       or  Absent, 

or  Abnormal. 


1 


Temporarily. 
Permanently. 


Aural  Symptoms: 

7.  Hearing  may  be  (in  pharyngeal 
and  nasal  disease  only) 


Impaired. 
Abnormally  acute. 
Painful. 


} 


Temporarily. 
Permanently. 


Note  facts  concerning  aural  discharges,  vertigo  and  tinnitus. 
[For  further  details  of  aural  symptoms  see  'Special  Aural  Forms,'  and  chapter  cn 
Throat  Deafness.'] 


go 


DISEASES  OF  THE  THROAT  AND  NOSE. 


B. 


r. 


D. 


Fig.  LVL— Outlines  of  (A)  Falices,  (B)  Posterior  Nares,  (C)  Section  of 
Nares,  and  (D)  Larynx,  for  Note-taking. 

8.  Pain  or  altered  sensation  may  be  experienced  in  exercise  of  any  of  the  above 
functions,  or  may  be  irrespective  of  them,  and  may  then  be  occasional  or  persistent. 

B.  PiiYsicAf.  OR  Objective  —  Larynx,  Fauces,  Pharynx  and  Nose. 


I.  Colour  may  b« 


Increased 
{Hypercemia), 
Diminished 
{Anccniia  or 
Hypo-ceviid). 
Altered. 


Uniformly 
or 

Partially. 


f Swelling — CEdematous  infiltration—  Thickening — Submu- 
cous deposit.    Bony  and  cartilaginous  hypertrophy. 
2.  Form,  texture,  .  ^^^s  of  tissue-Ulceration. 
and  mobility^ 
may  be  altered 


by 


Cicatricial  narrowing. 
Compression. 

Paralysis,  bi-  or  uni-lateral. 
^New  formations. 
3.  Position  (relative)  may  be  altered  )  Intrinsic, 
by  disease.  j  Extrinsic. 

Deficient.'  Y^'l"^^^  consistence,  and 

Arrested. 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES.  91 


C.  Miscellaneous  : 
External : 


General 


r  Circulation. 
I  Temperature. 
"I  Respiration. 


Lymphatic  glands. 

Digestion. 

Nutrition. 


Commemorative 


etc.,  etc. 

Individual  and  family  history  of  previous  attacks, 
heredity,  etc. 


A.  FUNCTIONAL  OR  SUBJECTIVE  SYMPTOMS. 

I.  The  Voice  may  be  natural  in  speaking,  and  modified  only  in 
singing,  the  upper  or  lower  notes  being  lost,  but  the  ordinary 
speaking  voice  being  unaffected  ;  or  difficulty  may  be  experienced 
in  passing  from  or  to  one  or  other  register  of  the  singing  voice. 
The  sustaining  power  of  either  the  singing  or  speaking  voice  may 
be  diminished,  the  vocal  organ  becoming  more  or  less  quickly 
fatigued.  [It  is  often  well  to  test  the  voice  by  the  piano,  marking 
on  what  notes  or  in  what  register  the  voice  fails.]  The  voice 
may  be  continuously  hoarse,  or  may  be  uncertain,  i.e.,  sometimes 
natural  or  only  slightly  husky,  at  other  times  passing  involuntarily 
into  falsetto  or  into  deep  bass.  It  may  be  muffled  or  veiled.  It 
may  be  unusually  shrill  or  jerky.  It  may  be  strained  and  difficult. 
It  may  be  lost  in  speaking,  though  in  involuntary  vocal  acts,  such 
as  coughing  and  laughing,  it  may  be  phonetic ;  and,  lastly,  it  may 
be  entirely  lost,  and  constitute  the  condition  known  as  aphonia. 

[In  T/ie  Nome7iclattire  of  Diseases,  drawn  up  by  the  Royal  College  of  Physicians) 
'  Aphonia  '  is  entered  as  a  disease  ;  and,  unfortunately,  this  error  has  been  perpetuated, 
not  only  in  some  systematic  treatises  on  medicine,  but  even  in  special  works  on  affec- 
tions of  the  throat.] 

In  pharyngeal  and  naso-pharyngea!  affections,  the  phonetic 
quality  of  the  voice  will,  cceteris  paribus,  not  be  impaired,  though, 
articulation  being  interfered  with,  it  will  often  sound  thick  or 
muffled,  or  it  will  be  quite  altered  in  tone,  acquiring  a  nasal 
character.  In  this  case  it  will  be  deficient  in  nasal  resonance,  or 
affected  by  a  nasal  *  twang.' 

Speech  may  be  painful;  it  maybe  defective  in  the  pronunciation 
of  only  certain  consonants,  as  the  palatal  or  guttural,  the  labial  or 
the  nasal;  and  it  is  of  course  important  to  determine  whether  such 
defects  of  speech  or  articulation  depend  on  central  or  peripheral 
nerve  changes,  or  on  mechanical  obstruction  to  proper  muscular 
movements  and  of  cavities  of  resonance. 

2.  Respiration  may  be  altered ;  irregularities  in  this  function 
being  conveniently  divided  into  three  groups  :  (i)  Those  due  to 
variations  in  the  quality,  quantity,  and  pressure  of  blood  (central 
and  peripheral) ;  (2)  those  primarily  due  to  some  defect  in  the 
respiratory  nervous  mechanism ;  (3)  those  induced  by  physical 
changes  in  or  near  the  respiratory  tract. 


92 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Dyspnoea  or  difficult  breathing,  is  due  primarily  to  deficient 
supply  of  oxygen,  for  which  any  of  the  above  groups  may  be 
responsible,  e.g.,  anaemia,  haemorrhage,  central-growths,  laryngeal 
stenosis,  etc. 

Apncea  is  a  condition  of  arrested  or  slowed  breathing,  due  to 
inhibition  of  the  respiratory  centre,  through  the  vagus  or  its 
branches,  irrespectively  of  any  variation  in  the  quantity  or  quality 
of  the  air  supply. 

Hyperpncea  simply  implies  exaggerated  or  hurried  breathing, 
due  to  functional  causes. 

Ortlwpncea  is  a  condition  in  which  the  patient  can  only  breathe 
in  the  semi-recumbent  posture,  as  occurs  in  asthma,  cardiac 
diseases,  etc. 

Cheync- Stokes  breathing  is  characterized  by  inequality  in  depth 
and  rhythm  of  the  respiratory  movements,  due  to  any  cause  which 
may  influence  the  quantity,  quality,  or  pressure  of  the  blood 
supply  to  the  respiratory  centre,  e.g,,  anaemia,  toxaemia,  heat- 
stroke, cardiac  diseases,  haemorrhage,  etc. 

Independently  of  disease,  the  breathing  may  be  deeper  or 
shallower  than  the  normal.  So  many  affections  of  the  voice  are 
the  result  of  imperfections  in  the  respiratory  act,  that  a  careful 
examination  as  to  the  mode  in  which  the  patient  fills  his  chest, 
and  of  his  vital  capacity  as  ascertained  by  the  spirometer,  will 
often  afford  a  valuable  indication  for  diagnosis.  Briefly,  the  general 
defects  under  this  head  are  as  follow  :  I.  Imperfect  chest  expan- 
sion, the  act  being  confined  to  lateral  expansion  of  the  ribs  with- 
out limitation  in  the  movemicnt  of  the  diaphragm,  descent  of 
which  is  necessary  for  full  deep  breathing.  II.  Exaggerated  ex- 
pansion by  elevation  of  the  clavicles  and  scapulas.  III.  Imperfect 
control  of  the  ex-spiratory  act,  the  air  being  emitted  either  before 
the  vocal  cords  are  made  ready  to  vibrate,  or  in  undue  amount  for 
the  performance  of  the  vocal  act. 

3.  Cough. — This  may  amount  to  slight  irritable  hacking  or 
*  hemming,'  or  it  may  have  all  the  characters  of  true  cough.  Its 
phonetic  quahty  may  vary  :  thus  it  may  be  hoarse,  barking,  or 
metaUic,  stridulous  or  aphonic.  It  may  be  accompanied  by  pain, 
may  occur  only  on  rising  in  the  morning,  on  exertion,  on  lying 
down,  after  meals,  on  change  of  temperature,  or  after  walking  ; 
or  it  may  he  frequent  and  continuous.  It  may  be  short,  sharp, 
and  paroxysmal,  or  suffocative;  and,  lastly,  it  may  occasion 
retching  and  even  vomiting. 

Stoerk,  in  a  pamphlet  published  in  Vienna  in  1878,  has 
drawn  attention  to  the  fact  that  there  are  certain  '  cough-spots ;' 
namely,  the  inter-arytenoid  fcld,  the  posterior  wall  of  the  larynx 
nnd  trachea,  the  under  surface  of  the  vocal  cords,  and  the  bifurca- 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES.  93 


tion  of  the  trachea.  He  does  not  consider  accumulation  of  mucus 
in  the  smaller  bronchi  causative  of  cough  until  it  reaches  one  of 
the  points  above  mentioned.  Careful  examination  of  these  sugges- 
tions has  convinced  the  author  of  the  accuracy  of  Stoerk's  obser- 
vations ;  and  it  need  hardly  be  said  that  they  are  of  the  highest 
diagnostic  importance.  It  may  be  added,  however,  that  the  cause 
of  cough  by  reflex  irritation  is  hardly  explained  by  the  learned 
Viennese  professor.  Probably  he  would  consider  it  as  belonging 
to  a  separate  category. 

The  Sputum  may  vary  considerably  in  quantity  within  the 
limits  of  health.  When  the  larynx  only  is  affected,  the  cough, 
unless  there  be  ulceration,  is  accompanied  by  but  little  secretion, 
the  mucus  being  expelled  in  small  gelatinous  pellets,  more  or  less 
discoloured  by  impurities  of  atmosphere.  Expectoration  may  be 
either  free  and  mucous,  as  in  chronic  congestion ;  muco-purulent 
after  acute  inflammation  ;  purulent,  as  in  the  bursting  of  abscesses; 
frothy,  as  in  phthisis  and  carcinoma;  clear  and  glairy,  as  in 
stenosis ;  and  accompanied  by  blood  in  some  cases,  in  which 
there  is  loss  of  tissue. 

Hsmoptysis  rarely  occurs  except  when  the  lungs  are  affected 
in  phthisis,  or  in  cancer  of  the  larynx  or  pharynx.  Streaks  of 
blood  are  occasionally  observed  in  the  expectoration  accompany- 
ing some  minor  diseases  of  both  pharynx  and  larynx.  A  sensation 
to  taste,  and  sometimes  the  actual  presence  of  blood  in  the  mouth 
on  rising  from  sleep,  is  characteristic  of  varix  of  the  tongue  and 
mouth,  of  the  pharynx,  and  possibly  of  the  oesophagus — the  last  a 
condition  to  which  attention  has  recently  been  drawn  by  Zenker, 
Rokitansky,  and  others.  I  have  also  known  it  occur  in  connec- 
tion with  undue  vascularity  of  the  inferior  turbinated  bone,  with- 
out epistaxis. 

In  malignant  disease,  and  whenever  there  is  caries  or  necrosis,  the 
expectoration  will  be  of  foetid  colour,  and  may  contain  blood  pigment. 

In  laryngorrhoea,  and  in  blenorrhoea,  a  disease  described  at  some 
length  by  Stoerk,  the  secretion  is  excessive. 

4.  Deglutition. — This  may  be  painful  {odynphagia),  difficult 
(dysphagia),  or  impossible  (aphagia). 

In  considering  the  relative  importance  of  this  symptom,  it  is 
necessary  to  find  out  in  which  act  of  deglutition  difficulty  or  pain 
occurs — whether,  i,  in  propulsion  of  the  bolus  behind  the  anterior 
pillars,  as  in  acute  quinsy  ;  2,  in  the  closure  of  the  naso-pharyn- 
geal  space,  and  elevation  of  the  root  of  the  tongue,  which  act 
sends  the  morsel  into  the  middle  of  the  pharynx,  as  seen  after 
diphtheria  and  in  syphilis ;  3,  in  the  passage  of  the  food  from  the 
pharynx  into  the  oesophagus,  as  in  tuberculosis  ;  or,  4,  in  the 
oesophagus  itself,  as  in  stricture  of  that  region. 


94 


DISEASES  OE  THE  THROAT  AND  NOSE. 


Dysphagia  may  be  due  to  a  paresis  of  constrictors,  as  in  patients 
with  defective  teeth  ;  to  an  obstruction  by  inflammation  or  abscess 
of  the  passages  of  the  fauces,  pharynx,  or  oesophagus;  or  to  intrinsic 
nervo-muscular  disorders  ;  or,  again,  to  thickening  and  ulceration 
of  the  velum,  pharynx,  or  epiglottis,  in  which  case  the  food  either 
returns  through  the  nares  or  passes  into  the  larynx.  Extraneous 
causes  are  :  mediastinal  tumours,  aneurisms,  enlarged  bronchial 
glands,  and  carcinomatous  deposits  in  the  sheath  of  the  oesophagus. 
Occasionally  dysphagia  is  caused  by  ulceration,  or  new  formations 
in  the  neighbourhood  of  the  inter-arytenoid  folds,  or  by  the  pres- 
sure of  an  extrinsic  tumour,  as  of  an  enlarged  thyroid  gland. 
Dysphagia  may  be  modified  according  to  the  nature  of  the  food 
taken,  whether  solid  or  fluid,  warm  or  cold,  piquant  or  bland,  and 
may  be  paroxysmal  and  spasmodic,  or  continuous  and  persistent. 

Odynphagia  is  characteristic  not  only  of  tonsillar  difficulty,  but 
also  of  tuberculous  or  malignant  ulceration  of  the  epiglottis.  On 
the  other  hand,  in  syphilitic  ulceration  and  thickening,  pain  in 
swallowing  is  neither  a  prominent  nor  even  a  usual  symptom  ; 
and  in  lupus,  a  disease  of  the  throat  which  is  by  no  means  so  rare 
as  has  been  generally  supposed,  absence  of  pain  is  even  more 
marked  than  in  syphilis,  and  serves  to  differentiate  it  from  tubercle. 

Aphagia  rarely  occurs,  except  in  very  advanced  stages  of 
pharyngo-laryngeal  disease,  or  as  the  result  of  malignant  obstruc- 
tion of  some  portion  of  the  swallowing  tract.  Cough  following 
deglutition  may  imply  regurgitation  of  fluid  into  the  larynx,  from 
imperfect  action  of  the  epiglottis,  or  may  be  an  indication  of  a 
fistulous  communication  between  the  trachea  and  gullet. 

5.  Nasal  Respiration  is  often  obstructed  in  certain  pharyngeal 
diseases,  and  from  the  presence  of  new  growths,  and  hypertrophies 
in  the  naso-pharyngeal  and  nasal  cavities.  No  examination  of 
the  throat  is  complete  without  careful  inspection  of  the  nasal 
passages  through  both  the  anterior  and  posterior  nares,  and  also 
where  symptoms  point  to  disease  of  the  naso-pharynx,  by  means 
of  the  index-finger  introduced  upwards  behind  the  velum  :  these 
are  points  still  much  neglected  both  in  precept  and  practice. 
Impediment  to  freedom  of  nasal  respiration  is  easily  ascertained 
by  directing  the  patient  to  exhale  by  each  nostril,  the  opposite 
one  and  the  mouth  being  firmly  closed.  The  distinction  between 
the  current  and  note  of  the  expired  breath,  in  the  case  of  diminu- 
tion of  normal  calibre,  between  a  hypertrophy  or  a  polypus,  is 
very  marked,  and,  although  difficult  to  describe,  is,  after  a  little 
practice,  not  difficult  of  discernment. 

In  certain  pharyngeal  diseases  also  there  is  a  disagreeable  odour 
in  the  ex-spired  breath,  and  it  is  important  to  ascertain  the  point 
of  origin  of  the  stench.    In  many  instances,  neither  ocular  nor 


THE  GENERAL  SExMEIOLOGY  OF  THROAT  DISEASES.  95 


digital  examination  will  suffice,  and  the  observer's  olfactory  sense 
must  be  called  to  assistance.  If  the  patient,  firmly  closing  his 
nostrils,  forcibly  exhales,  and  the  ex-spired  breath  is  offensive,  the 
cause  is  situated  either  in  the  larynx  or  oesophagus,  pharynx  of 
tonsils,  or  it  may  be  caused  by  decaying  teeth,  or  by  gastric 
derangement.  If,  on  the  other  hand,  with  mouth  firmly  closed, 
nasal  ex-spiration  gives  a  foul  odour,  the  disease  is  in  the  nasal 
cavity  itself.  By  closing  first  one  and  then  the  other  nostril,  the 
surgeon  may  still  further  localize  the  seat  of  the  disease.  Another 
most  valuable  diagnostic  point  is  whether  the  patient  is  con- 
scious of  the  offensiveness  of  his  breath.  If  so,  the  cause  is  an 
obstruction  from  presence  of  polypus,  or  other  growth.  If 
not,  the  disease  is  of  secreting  surface.  By  washing  out  the 
nostril  with  some  disinfecting  solution,  as  Sanitas,  Condy's  fluid, 
or  boracic  acid  solution,  it  is  not  difficult  to  determine  whether 
this  foul  odour  be  due  to  morbid  alteration  or  retention  and  con- 
sequent putrefaction  of  mucous  secretion,  or  whether  it  be  the 
result  of  necrosis  or  caries.  In  the  latter  case  the  stench  is  seldom 
entirely  removed,  and  is  of  a  much  more  penetrating  character. 

6.  The  sense  of  smell  may  be  impaired  from  any  of  the  causes 
likely  to  impede  nasal  respiration,  from  disorder  of  mucous  secre- 
tion, and  from  many  diseases  extending  from  the  pharynx  to  the 
naso-pharynx.  In  the  case  of  loss  of  this  sense  due  to  nasal 
polypus,  the  growth  is  to  be  looked  for  in  the  superior  passages. 
The  author  has  seen  two  cases  of  complete  anosmia  cured  by 
removal  of  an  elongated  uvula. 

The  sense  of  taste  is  generally  disordered  where  that  of  smell 
is  impaired.  It  will  be  probably  limited,  in  the  class  of  diseases 
treated  in  these  pages,  to  inability  to  distinguish  flavour  of  food 
and  bouquet  of  wine — that  is,  to  so  much  of  the  sense  as  is 
dependent  on  the  olfactory  nerve ;  impressions  on  the  palate  due 
to  the  temperature  and  piquancy  of  food  being  unchanged. 

7.  Hearing"  is  impaired  In  relation  to  enlarged  tonsils  by  inter- 
ference of  the  enlarged  glands  with  the  action  of  the  palate  and  its 
muscles,  to  thickening  of  the  pharyngeal  orifice  of  the  tubes,  or  to 
disease  of  mucous  s-ecretion  of  the  naso-pharynx,  or  to  extension  of 
any  catarrhal  inflammation  from  this  region  to  the  middle  ear. 
To  be  thoroughly  acquainted  with  the  study  of  throat  diseases  it  is 
necessary  to  acquire  facility  in  examining  the  auditory  apparatus, 
and  to  be  able  to  recognise  the  importance  of  at  least  the  more 
common  variations  in  the  appearances  of  the  drumhead,  the 
value  of  tests  by  watch  and  tuning-fork,  and  how  to  pass  a 
Eustachian  catheter,  or  to  use  a  PoHtzer  air-bag.  It  is  difficult 
to  comprehend  how  an  aurist  can  work  satisfactorily  without 
having  studied  the  physiology  and  pathology  of  the  throat  and 


96 


DISEASES  OF  THE  THROAT  AND  NOSE. 


nose,  or  how  one  who  occupies  himself  with  diseases  in  the  latter 
region  can  fail  sometimes  to  be  at  a  loss,  unless  he  has  worked 
also  at  aural  surgery.  It  would  be  beyond  the  scope  of  this  work 
to  make  it  exhaustive  of  all  aural  diseases  in  relation  to  the 
throat ;  but  I  have  appended  a  chapter  suggestive  of  their  study, 
and  also  tolerably  extended  directions  as  to  hov/  to  examine  an 
aural  case. 

8.  Pain  is  an  important  element  of  diagnosis,  which  will  be 
considered  when  dealing  in  detail  with  the  various  diseases  in 
which  it  occurs.  Almost  all  reflex  nervous  pains  and  sensations 
may  be  traced  to  objective  sources,  and  should  not  be  treated,  as 
is  too  frequently  the  case,  as  entities.  Amongst  the  commonest 
disturbances  of  ordinary  sensation  are  dryness,  the  presence  of  a 
foreign  body  in  the  throat,  a  hair,  gravel,  or  a  lump ;  or  a  feeling 
of  heat,  tinghng,  weight,  or  nausea.  All  these  may  be  associated 
with  fatigue  in  the  performance  of  functional  acts,  which  may 
also  occur  independently. 

B.  PHYSICAL  OR  OBJECTIVE  SYMPTOMS. 
Those  deviations  from  the  normal  condition  which  are  revealed 
to  the  observer  by  reflected  light  will  be  more  especially  considered 
under  this  heading. 

1.  Colour  of  the  parts  may  be  increased,  diminished,  or  altered. 
It  may  be  increased  or  hypersemic  in  acute,  subacute,  or  chronic 
inflammation;  it  will  be  diminished  or  anaemic  in  general  anaemia, 
and  in  certain  toxic  affections ;  changed  to  a  bluish  tinge  in 
cyanosis ;  yellowish  or  greenish  in  jaundice ;  grey  as  in  the  earlier 
stages  of  phthisis,  and  altered  in  oedematous,  purulent,  and  tuber- 
culous infiltration.  The  colour  of  new  formations  varies  of  course 
with  their  pathological  nature,  ranging  from  white  or  pale  grey  to 
deep  red  or  purple. 

The  change  of  colour  may  be  general  or  partial ;  thus  one  vocal 
cord  may  be  congested,  the  other  normal ;  the  epiglottis  ma}'  be 
congested,  and  the  arytenoids  healthy,  or  vice  versa.  The  colour 
may  be  altered  in  patches,  as  in  the  congestion  of  the  vocal  cords 
of  secondary  syphilis.  The  colour  of  ulcerations  varies  also  accord- 
ing to  their  nature.  It  must  not  be  forgotten  that  the  cartilaginous 
part  of  the  vocal  cords,  especially  in  the  case  of  those  who  constantly 
use  the  voice,  is  often  slightly  pink  in  colour,  and  this  appearance 
must  not  be  mistaken  for  the  result  of  disease. 

2.  Form. — The  calibre  of  the  glottis  is  seldom  increased,  as, 
even  if  there  is  loss  of  tissue  by  ulceration,  there  is  generally 
attendant  thickening.    The  calibre  may  be  diminished  by  all . 
causes  tending  to  infiltration,  serous,  purulent,  tubercular,  syphi- 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES. 


97 


Htic,  or  malignant ;  by  new  formations,  and  by  paralysis  of  one 
or  more  intrinsic  muscles.  As  a  result  of  this  last  cause,  the 
mobility  of  the  vocal  cords,  i.e.  their  power  of  lateral  approxima- 
tion and  separation,  may  be  impeded,  or  tension  may  be  impaired 
on  one  or  both  sides.  Such  paralysis  may  arise  from  pressure 
directly  on  the  nerve-supply,  from  central  or  peripheral  disease, 
from  interstitial  disease  of  muscles,  or  from  mechanical  causes. 

Impairment  of  movement  of  the  epiglottis  is  due  to  mechanical 
causes,  to  relaxation  of  the  glosso-epiglottic  ligaments,  or,  it  may 
be,  to  disease  of  the  superior  laryngeal  nerve.  The  texture  or 
surface-appearance  will  be  changed  under  the  varying  conditions 
of  the  inflammatory  process  above  alluded  to. 

3.  Position. — Certain  portions  of  the  larynx  may  be  displaced, 
which  might  be  considered  by  some  as  constituting  only  an  altera- 
tion in  form,  or  the  whole  organ  may  be  pushed  more  or  less  out 
of  position.  Partial  displacement  is  generally  due  to  intrinsic 
disease,  especially  syphilitic,  while  displacement  of  the  entire 
larynx  is  the  result  of  disease  in  the  neighbouring  structures,  as 
cancer,  abscesses,  bronchocele,  and  other  glandular  affections. 

4.  Secretion  may  be  excessive,  defective,  or  altered. 

The  character  of  the  secretion  of  the  salivary  and  other  glands 
is  an  important  element  of  diagnosis,  and  is  to  be  considered 
independently  of  the  question  of  the  nature  of  sputa. 

C.  MISCELLANEOUS  AND  COMMEMORATIVE 
SYMPTOMS. 

Into  these  it  is  unnecessary  to  enter  at  any  length.  The  state 
of  the  tongue,  the  pulse,  the  temperature,  the  appetite  and 
nutrition,  the  action  of  the  liver,  kidneys,  and  uterus,  are  all  of 
as  much  importance  in  laryngeal  disease  as  in  any  other.  This 
point  is  one  to  be  remembered,  as  in  many  cases  the  special 
method  of  examination  seems  to  tell  us  so  much  that  we  feel 
inclined  to  make  a  diagnosis  of  the  malady  without  asking  a 
question  of  the  patient.  On  the  other  hand,  it  will  not  unfre- 
quently  occur  that  only  by  such  general  examination  can  a  cause 
be  found  for  a  disease  believed  by  the  patient  to  be  purely  local, 
and  in  such  a  case  the  laryngoscope  will  be  of  value  in  a  negative, 
but  none  the  less  practical  sense. 

As  regards  the  use  of  the  laryngeal  probe,  so  far  from  being,  as 
some  authors  insist,  an  instrument  of  the  first  importance,  it  is 
one  that  it  is  very  rarely  necessary  to  employ.  Pretty  well  every- 
thing that  is  necessary  to  be  known  can  be  ascertained  by  visual 
inspection.  It  is,  however,  of  service  to  the  surgeon  who,  not 
being  very  familiar  with  the  introduction  of  instruments  into  the 

7 


DISEASES  OF  THE  THROAT  AND  NOSE. 


larynx,  would  wish  to  learn  before  operating  the  exact  direction 
that  his  instrument  should  take  for  the  accurate  cauterization  c  f 
ulcers  or  the  removal  of  new  growths. 

In  external  examinations  it  is  important  to  examine  the  glands 
in  the  suboccipital  region  for  corroboration  of  syphilis,  and  those 
in  the  parotid  and  submaxillary  region  for  evidence  of  suspected 
mahgnant  or  strumous  disease.  Much  may  be  learned  by  ex- 
ternal examination  of  the  larynx  itself.  There  may  be  redness 
and  sweUing,  as  in  perichondrial  disease.  It  may  be  seen  to 
be  pushed  out  of  the  median  hne  ;  or,  as  in  the  cases  of  cancer 
and  syphilitic  infiltration,  its  mobility  will  be  felt  to  be  impeded. 
There  may  also  be  an  expansion  of  the  larynx  either  symmetrical 
or  unilateral.  Stethoscopic  examination  will  also  be  necessary 
to  ascertain  the  condition  of  the  lungs  in  cases  of  chronic  laryn- 
gitis, or  wherever  there  seems  reason  to  suspect  the  presence  of 
tubercle.  Such  examinations  should  be  carefully  repeated  from 
time  to  time.  The  general  utility  of  auscultation  of  the  larynx  or 
trachea  is  doubtful,  though  it  is  certainly  of  some  diagnostic  value 
in  some  affections  of  the  oesophagus. 

Careful  examination  of  the  heart  and  large  vessels,  and  of  the 
mediastinum  for  enlarged  glands,  or  for  intra-thoracic  growths,  is 
all-important  where  there  is  the  least  interference  with  mobility  or 
co-ordinative  action  of  the  vocal  cords.  The  sphygmograph  and 
ophthalmoscope  also  frequently  aid  the  observer  in  a  most  important 
degree  to  the  obtaining  of  an  accurate  diagnosis.  An  interesting 
example  of  the  indication  afforded  by  the  pulse  may  be  seen  in  its 
depression  almost  even  to  obliteration  which  takes  place  during  the 
act  of  inspiration  in  cases  of  laryngeal  obstruction,  such  as  croup. 

The  history  of  the  patient,  both  personal  and  family,  is  of 
primary  importance,  and  is  equally  indispensable  for  the  purposes 
of  diagnosis,  prognosis  and  sound  treatment. 

Information  of  the  greatest  value,  both  in  diagnosis  and  in 
prognosis,  is  to  be  obtained  from  observations  of  the  weight  at 
regular  intervals  of  the  patient,  as,  for  instance,  in  distinguishing 
between  syphilis  and  cancer,  and  in  cases  of  chronic  laryngitis, 
with  premonitory  signs  of  phthisis.  It  is  equally  essential,  in 
such  circumstances,  to  ascertain  whether  there  are  any  nocturnal 
exacerbations  of  temperature.  As  already  indicated,  there  is  a 
certain  class  of  cases  where,  when  positive  symptoms  are  absent^ 
the  spirometer  is  of  value  as  indicating  deficiency,  and  possibly, 
under  treatment,  increase  of  lung  capacity. 

The  following  table,  taken  from  Voice,  Song,  and  Speech,  will  be 
found  of  service,  as  affording  data  for  comparison  on  this  and 
other  desirable  details  of  information  : 


THE  GENERAL  SEMEIOLOGY  OF  THROAT  DISEASES.  99 


TABLE  SHOWING  THE  AVERAGE  HEIGHT,  WEIGHT, 
BREATHING  CAPACITY,  AND  CHEST-GIRTH  OF  ADULT 
MALES  AND  FEMALES  IN  ENGLAND. 

DRAWN  UP  FOR  THE  AUTHORS  OF  'VOICE,  SONG,  AND  SPEECH,'  BY 
CHARLES  ROBERTS,  ESQ.,  F.R.C.S., 


From  Data  collected  by  the  Anthropometric  Committee  of  the 
British  Association  for  the  Advancement  of  Science. 


MALES. 

FEMALES. 

Chest 
Girth, 
after 
Expira- 
tion.* 

Weight, 
including 
Clothes. 
t 

Breath- 
ing 
Capacity. 

Height, 

WITHOUT 

Shoes. 

Breath- 
ing 
Capacity. 

+ 

-♦- 

Weight, 
including 
Clothes. 
t 

Chest 
Girth 

BELOW 

Breasts. 

Inches. 

38-9  • 

38-4 

37-8 

37-3 
367 
36-2 
357 
35'i 
34-6 
34  "o 
33-5 
33-0 
32-4 
31-9 
31-3 

Lb. 

165-6 
163-3 

161 -Q 
1587 
156-4 
I54I 
151-8 

i49'5 
147-2 
144-9 
142  6 
140-3 
138-0 

1357 
1 33 '4 

Cubic 
inches. 
290 
280 
270 
260 
250 
240 
230 
220 
210 
200 
190 
180 
170 
160 
150 

Inches. 
72 

71 

70 
69 
68 

67 
66 

65 
64 

63 
62 
61 
60 
59 
58 

Cubic 
inches. 
238 
230 
221 
213 
204 
196 
187 
179 
170 
162 
153 
145 
136 
128 
119 

Lb. 

141-1 
139-- 
137-2 
135-2 
i33"3 
131-3 
129-4 

127-4 
125-4 
123-5 
121-5 
119-6 
117-6 
115-6 
113-7 

Inches. 

327 
32-2 
317 
31-2 

308 

30-4 
30 'O 

29-5 
29-0 
28-5 
28-1 
27-6 
27-2 
266 
261 

*  INIilitary  measurement :  Tape  round  chest  at  nipples,  arms  hanging  loosely  by  the 
side.    Let  the  patient  count  from  one  to  ten,  then  read  off  the  measurement, 
t  The  average  weight  of  indoor  clothes,  including  the  shoes,  is,  for  the 

professional  class    -  -  -  -  -  -  -  -     8  lb. 

Average  for  working-class     "  -  -  •  -  •  -10  lb. 


Average  for  men       -  •  -  -  -  •  •  -     9  lb. 

The  average  weight  of  a  woman's  dress  has  not  been  accurately  ascertained,  but  it  is 
among  female  shop-assistants  and  school  teachers  about  7  lb.  We  are  very  much  in 
want  of  information  as  to  the  weight  of  ladies'  dresses ;  the  average  is  probably  nearly 
equal  to,  or  even  in  excess  of,  that  of  the  male  working-class. 

X  Breathing  capacity  of  males  :  Hutchinson's  table,  published  in  1846,  gives  a  difference 
of  only  8  cubic  inches  for  each  inch  of  height.  The  above  table  gives  a  difference  of 
10  inches  for  each  inch  of  height,  and  a  relative  increase  of  upwards  of  20  cubic  inches 
as  compared  with  Hutchinson.  These  differences  are  very  probably  the  result  of  the 
accuracy  of  the  instruments  now  employed. 

Breathing  capacity  of  females  gives  in  this  table  an  average  decrease  of  power,  as 
compared  with  males,  of  only  20  per  cent.,  instead  of  33  per  cent.,  as  estimated  by 
Hutchinson.  Thus,  having  made  allowance  for  the  relative  increase  granted  by  us  for  men, 
a  female  at  66  inches,  who  would  have  breathed  142  cubic  inches  according  to  the  old 
table,  is  now  found  to  have  a  vital  capacity  of  187  cubic  inches. 


CHAPTER  VIL 


THERAPEUTICS  OF  THROAT  DISEASES  :  MEDICAL,  SURGICAL, 
DIETETIC,  AND  HYGIENIC. 

In  considering  the  therapeutics  of  throat  diseases,  special  attention 
will  necessarily  be  given  to  those  remedies  and  methods  of  treat- 
ment which  have  a  topical  action  ;  but  it  must  not  be  supposed 
on  this  account  that  general  treatment  is  unnecessary  in  diseases 
of  the  throat ;  on  the  contrary,  each  year's  experience  the  more 
convinces  me  that  it  is  often  equally  futile  to  treat  thi;;oat  diseases 
by  only  topical,  as  it  is  by  only  general  means,  and  with  this  view 
many  formulae  for  suitable  constitutional  remedies  are  appended. 

Lengthened  reference  to  general  methods  of  treatment  is 
omitted,  therefore,  not  because  such  treatment  is  considered  unim- 
portant, but  because,  on  the  principle  that  sound  general  medical 
and  surgical  knowledge  should  precede  a  study  of  the  special 
branches  of  practice,  it  is  to  be  presumed  that  most  readers  of 
these  pages  will  be  acquainted  with  the  principles  of  constitutional 
therapeutics. 

General  treatment  is  always  specially  indicated  when  the  throat 
affection  is  symptomatic  of  any  general  malady — scrofula,  phthisis, 
or  syphilis,  for  example — or  when  it  occurs  in  the  course  of  a 
continued  fever,  of  one  of  the  exanthemata,  of  diphtheria,  or  a? 
a  result  of  zymotic  influences.  In  other  cases  also  a  constitutional 
diathesis  must  be  combated  concurrently  with  the  local  trouble. 

In  very  many  local  manifestations,  however,  general  treatment 
is,  if  not  contra-indicated,  at  least  unnecessary,  and  in  many 
cases  of  chronic  laryngitis  and  pharyngitis  the  influence  of  local 
treatment  will  be  markedly  beneficial  without  the  administration 
of  any  general  remedies  whatever. 

In  pursuing  local  treatment  it  is  necessary  to  consider  the  effect 
of  remedies  on  the  vascular  supply,  on  the  mucous  and  salivary 
secretion,  on  loss  of  tissue,  on  nervo-muscular  action,  and  on  the 
arrest  of  development  or  the  eradication  oi  new  formations.    It  is. 


THERAPEUTICS  OF  THROAT  DISEASES. 


lOI 


therefore,  exceedingly  difficult  to  separate  medical  from  surgical 
therapeutics,  and  both  will  be  considered  under  one  chapter. 

In  employing  topical  remedies  it  is  always  well  to  bear  in  mind 
the  physiological  functions  of  the  part  to  which  the  remedy  is  to 
be  applied.  For  instance,  the  function  of  the  larynx  being  to 
afford  passage  to  air  and  not  to  liquids,  the  use  of  sprays  to  this 
part — at  any  rate,  in  any  form  except  that  in  which  the  atomiza- 
tion  is  so  fine  as  to  constitute  rather  a  cloud  than  a  shower — is 
in  my  opinion  a  mistake ;  vapour  inhalations  are  much  more 
suitable  and  more  in  accordance  with  the  natural  function  of  the 
organ.  The  same  may  be  said  of  the  indiscriminate  practice  of 
blowing  powders  into  the  larynx,  and  of  the  administration  of 
snuffs  in  all  and  every  form  of  nasal  disease.  They  are  for  the 
most  part  unphysiological,  and  but  too  often  as  little  beneficial  as 
they  are  deleterious.  On  a  similar  principle,  whenever  applica- 
tions of  a  liquid  character  are  absolutely  necessary,  only  a  very 
small  quantity  of  the  liquid  should  be  applied  at  a  time  (other- 
wise spasm  of  the  glottis  will  be  caused),  and  the  area  of  appHcation 
should  be  as  far  as  possible  limited  to  the  exact  portion  affected. 

Topical  remedies  may  be  divided  into  two  classes  : 

1.  Those  which  can  be  administered  either  by  the  patient  or 

the  practitioner. 

2.  Those  which,  requiring  the  management  of  a  skilled  hand, 

can  be  administered  by  the  practitioner  only. 

The  first  class  includes  such  remedies  as  gargles,  lozenges, 
powders,  inhalations,  pharyngeal  and  nasal  sprays,  insufflations, 
douches,  and  pigments ;  and  all  kinds  of  external  applications. 

In  the  second  class  are  contained  laryngeal  applications  of  all 
kinds,  except  those  of  the  nature  of  inhalations,  and  all  forms  of 
operative  procedure. 

Class  I.  Gargles. — With  respect  to  the  value  of  gargles  con- 
siderable difference  of  opinion  exists,  and  it  is  an  undecided  point 
as  to  how  far  the  gargle  penetrates.  There  can,  however,  be 
little  doubt  that  this  depends  to  a  considerable  extent  on  the 
skill  of  the  patient  and  the  amount  of  practice  which  he  has  had. 
It  would  appear,  from  the  experiments  and  demonstrations  of 
M.  Guinier  and  others,  that  by  practice  gargles  may  be  allowed 
to  enter  the  larynx  itself  and  to  come  in  contact  with  the  vocal 
cords.  This  act  is  called  by  Guinier  laryngeal  gargling,  and  the 
following  is  briefly  the  method  of  use  :  A  comparatively  small 
amount  of  fluid  only  is  taken  into  the  mouth,  which  is  to  remain 
a  little  open.  The  patient  should  then  protrude  the  lower  jaw  so 
as  to  draw  away  the  epiglottis  from  the  laryngeal  vestibule  ;  and 


I02 


DISEASES  OF  THE  THROAT  AND  NOSE, 


on  half  uttering  a  vowel  sound  the  liquid  drops  into  the  larynx, 
and  provided  the  patient  can  prevent  himself  from  taking  an 
inspiration,  those  parts  above  the  level  of  the  vocal  cords,  will 
be  thus  thoroughly  laved.  Experience  compels  me  to  say  that 
laryngeal  gargling  is  by  no  means  an  easy  process. 

It  is  probable  that  in  the  ordinary  way  gargles  seldom,  if  ever, 
go  behind  the  anterior  pillars  of  the  fauces.  By  the  method  of 
Von  Troeltsch  they  may  be  made,  however,  to  come  in  close 
contact  not  only  with  the  parts  touched  in  the  ordinary  mode  of 
gargling,  but  also  with  the  posterior  wall  and  even  the  vault  of 
the  pharynx  and  the  Eustachian  tubes.  By  this  method,  con- 
traction of  the  pharynx  takes  place,  and  powerful  displacement  of 
superficial  parts ;  mucus  is  forced  out  of  the  glands,  and  any 
adherent  viscid  secretion  is  rubbed  off.  Von  Troeltsch  very  justly 
extols  the  remedial  gymnastic  significance  of  systematic  practice 
of  this  kind  in  insufficiency  of  the  muscles  of  the  Eustachian  tube 
(levator  and  tensor  palati)  in  cases  of  hypertrophy  of  the  mucous 
membrane.  The  following  are  the  directions  to  be  given  to  such 
patients  as  are  desired  to  employ  gargles  in  this  way :  '  Take  a 
mouthful  of  the  gargle,  hold  it  in  the  back  of  the  throat  with  the 
head  thrown  back,  then  closing  the  nose  with  finger  and  thumb, 
open  the  mouth  and  make  the  movements  of  swallowing  without 
letting  the  liquid  go  down  the  throat.  No  harm  need  be  feared  if 
some  of  the  hquid  should  happen  to  be  swallowed.' 

Gargles  are  also  of  some  value  as  mouth-washes,  even  if  their 
field  of  action  be  as  restricted  as  it  generally  is  ;  and  inasmuch  as 
some  patients  are  able  to  extend  that  action,  their  utility  will  in 
such  cases  be  proportionately  increased.  They  are  generally 
contra-indicated  when  there  is  actual  faucial  pain,  since  more  dis- 
comfort is  liable  to  be  caused  by  the  irregular  muscular  acts 
exercised  in  their  employment  than  relief  experienced  from  the 
specific  influence  of  their  ingredients ;  this  remark  more  espe- 
cially applying  to  tjie  ordinary  method  of  gargling. 

Gargles  are  used  for  their  antiseptic,  astringent,  sedative,  and 
stimulant  properties.  Formulae  of  gargles  having  those  respective 
actions  will  be  found  in  the  Appendix.  These  formulae  are 
generally  identical  with  those  contained  in  the  Central  Throat 
Hospital  Pharmacopoeia,  in  the  preparation  of  which  I  have  joined 
with  my  colleagues;  although  brought,  as  we  trust,  up  to  date, 
novelties  in  detail  are  only  introduced  after  passing  the  test  of 
experience.  The  hst  in  the  Appendix  is  limited  to  such  as  have 
been  tested  by  experience,  but  it  contains  almost  all  which  have 
been  found  of  distinct  value  in  our  conjoint  practice. 


THERAPEUTICS  OF  THROAT  DISEASES, 


In  the  case  of  children,  the  use  of  gargles  is  usually  impossible, 
and,  as  a  substitute  for  them,  it  is  an  excellent  plan  to  have  the 
drug  required  to  exercise  local  effect  made  into  a  powder  with 
white  sugar,  or  some  other  convenient  vehicle,  and  placed  on  the 
tongue.  If  allowed  to  remain  there  and  dissolve  gradually,  the 
topical  effect  of  the  remedy  will  be  produced  almost,  if  not  quite, 
as  well  as  if  a  gargle  had  been  used,  and  the  constitutional  effect 
be  enhanced.  This  method  is  of  course  only  applicable  when  the 
remedy  is  one  which  may  be  swallowed  with  impunity,  and  is  not 
of  a  nauseous  character.  As  a  local  application,  ice  is  of  great 
value,  not  only  as  an  anaesthetic  before  operation,  but  as  a  reme- 
dial agent  in  pharyngeal  disease,  tonsillitis,  etc.,  and  in  the  sore 
throat  of  scarlatina  and  diphtheria.  For  adults  nothing  is  more 
agreeable  than  simple  block  ice,  but  the  remedy  is  somewhat 
difficult  to  administer  to  children,  who,  suffering  from  pain  in 
swallowing,  are  unwilling  to  exercise  the  function  of  deglutition. 
In  these  cases  it  will  be  found  of  great  service  to  ice  the  food.  A 
simple  mixture  of  egg,  milk,  and  sugar,  uncooked,  and  iced,  is 
taken  with  avidity,  and  is  serviceable  both  as  a  nutriment  and  as 
a  remedy.  The  Wenham  Lake  Ice  Company  make  very  simple 
and  cheap  refrigerators. 

Lozenges. — The  lozenge  is  a  convenient  form  for  the  adminis- 
tration of  many  remedies.  It  should  be  remembered  that  by  the 
use  of  lozenges  we  get  not  only  the  immediate  local  effect,  but 
also  the  constitutional  action  of  the  drug ;  and  this  is  often 
greater  in  proportion  than  if  a  corresponding  amount  of  the 
remedy  had  been  taken  direct  into  the  stomach.  As  examples  of 
this  may  be  adduced  guaiacum,  a  comparatively  small  amount  of 
which,  given  in  the  form  of  a  lozenge,  will  produce  constitutional 
symptoms ;  also  the  effervescent  lozenges  of  Cooper  (Form.  20), 
containing  half  a  grain  of  calomel,  one  of  which,  taken  at  night, 
produces  far  more  effect  on  bile  secretion  than  two  or  three  grains 
would  if  taken  in  the  form  of  a  pill.  For  the  last  two  or  three 
years  I  have  administered  the  active  principles  of  Plummer's  pill 
in  the  form  of  an  effervescing  lozenge  (Form.  13),  producing  by 
this  means  a  much  quicker  and  more  certain  constitutional  action, 
and  with  considerable  benefit  to  the  local  condition  manifested 
in  the  cases  in  which  the  drug  has  been  indicated.  The  very 
powerful  effects  produced  by  sedative  lozenges,  which  contain  but 
very  moderate  doses  of  their  respective  anodyne  ingredients,  are 
also  well  known.  By  the  use  of  lozenges  the  salivary  secretion 
is  stimulated ;  this  fact  should  be  borne  in  mind  when  giving 
astringent  lozenges,  which  often  tend  to  increase  the  dryness  of 


I04  DISEASES  OF  THE  THROAT  AND  NOSE. 

the  throat  symptomatic  of  pharyngeal  relaxation,  unless  combined 
with  a  sialagogue,  as  chlorate  of  potash  (Form.  12,  16  and  17). 

The  British  Pharmacopoeia  contains  some  formulae  for  lozenges 
which  are  very  useful ;  but  a  drawback  to  them  consists  in  their 
hardness,  the  consequent  slowness  with  which  they  dissolve,  and 
their  liability  to  produce  erosion  of  the  mucous  membrane. 

To  obviate  these  inconveniences  the  ingredients  of  all  lozenges 
in  the  Throat  Hospital  Pharmacopoeia  were  incorporated  with  fruit- 
paste,  which  not  only  renders  them  more  palatable,  but  facilitates 
their  dissolution.  I  have,  however,  found  considerable  gastric 
derangement  ensue,  especially  in  the  case  of  children,  from  this 
f©rm  of  lozenge,  and  to  overcome  this  objection  I  have  for  some 
years  past  largely  utilized  liquorice  as  a  vehicle,  which  is  at 
once  demulcent  and  non-irritating.  It  has,  moreover,  the  further 
advantage  of  masking  the  nauseous  tastes  of  many  drugs  valuable 
to  administer  in  this  form.  The  extreme  saline  pungency  of 
chloride  of  ammonium,  for  example,  is  almost  entirely  removed 
when  given  in  combination  with  liquorice. 

Inhalations. — One  of  the  most  valuable  and  effective  methods 
of  applying  remedial  agents  to  the  throat  and  larynx  is  by  means 
of  inhalations.  Like  most  other  valuable  forms  of  treatment, 
however,  it  has  been  carried  too  far,  and  applied  without  due 
regard  to  the  proportion  of  anticipated  risk  and  benefit.  In- 
halations, as  used  by  various  authorities,  may  be  subdivided  into 
vapours,  aqueous  or  volatile,  atomized  fluids,  and  fumigations. 

Vapour  Inhalations. — These  are  either  moist  or  dry,  and  the 
moist  have  been  further  subdivided  into  hot,  when  the  tempera- 
ture of  the  moist  air  ranges  between  130°  and  150°  Fahr.,  and 
cold,  when  the  temperature  of  the  moist  air  is  from  60°  to  100° 
Fahr.  Dry  inhalations  can  be  taken  cold,  but  they  are  generally 
hot ;  that  is  to  say,  heat  is  applied  to  vaporize  certain  volatile 
matters,  the  fumes  of  which  are  inhaled.  In  my  practice  dry 
cold  inhalations  refer  to  mixtures  combined  with  the  vapour  of 
nascent  ammonia,  or  of  others  of  volatile  ingredients  to  be  used 
with  the  oro-nasal  inhaler,  which  will  be  presently  described. 

For  the  administration  of  steam  inhalations  a  suitable  ap- 
paratus will  be  convenient.  Various  forms  of  inhaler  have  been 
devised,  all  more  or  less  complicated  in  their  nature,  and  all 
possessing,  according  to  their  designers,  peculiar  advantages. 
That  devised  by  myself,  and  originally  made  for  me  by  Messrs. 
Corbyn,  and  known  as  Corbyn's  improved  double-valve  inhaler 
(Fig.  I VII.),  will,  I  believe,  be  found  simple  and  efficacious.  The 
hospital  inhaler  of  Martindale  is  an  excellent  and  cheap  instru- 


THERAPEUTICS  OF  THROAT  DISEASES. 


105 


ment,  and  that  of  Ellis  (sold  by  Arnold)  is  also  good.  The  more 
recent  inhalers  of  Messrs.  Maw's  manufacture  are  great  improve- 
ments on  those  form»erly  constructed.  The  Carrick  and  Eclectic 
inhalers  are  efficient,  but  they  are  very  complicated,  less  compact, 
and  much  more  expensive  than  those  above  named.  The 
cheapest  (efficient)  inhaler  with  which  I  am  acquainted  has  been 
devised  by  Mr.  Murch,  lately  Dispenser  of  the  Central  Throat  and 
Ear  Hospital,  and  merits  description  (Fig.  LVIIL).  It  consists 
of  an  ordinary  quart  glass  pickle-bottle,  closed  by  a  c®rk  bung 
perforated  for  tubes,  as  shown  in  the  illustration.  To  obviate  the 
necessity  for  a  thermometer,  the  label  is  so  placed  that  by  pouring 


Fig.  LVII.— Sectional  View  of  Corbyn's  Double-Valve  Inhaler,  as 
su(jGested  by  the  Author. 

cold  water  up  to  the  level  of  its  lower  border,  and  then  adding 
boiling  water  to  that  of  its  upper  border,  a  temperature  of  140°  to 
150°  Fahr.  is  attained.   The  cost  of  this  apparatus  is  one  shilHng. 

So-called  pocket-inhalers  are  useless  in  cases  of  disease. 

With  regard  to  the  method  of  using  the  inhaler,  the  following 
are  the  printed  directions  which  I  give  to  my  patients  with  their 
prescription ; 

*  For  Ordinary  Use. — The  medicament  being  added  to  a  pint 
of  hot  water  at  the  prescribed  temperature,  the  vapour  should  be 
inhaled  by  means  of  full  but  not  exaggerated  inspirations,  and 
should  then  be  gently  exhaled  through  the  nostrils  ;  in  this  manner 
six  to  eight  inhalations  may  be  taken  each  minute.' 


ic6 


DISEASES  OF  THE  THROAT  AND  NOSE. 


[If  our  object  be  to  treat  only  the  oral  cavity,  the  palate,  the 
pharynx  or  the  surface  of  the  epiglottis,  the  patient  must  be 
directed  to  take  shallow  respirations — avoiding  deep  ones  as 
much  as  possible.] 

*  In  cases  of  Obstruction  of  the  Passages  from  the  Throat 
to  the  Ear,  it  is  sometimes  desirable  that  the  vapour  should  be 
forced  towards  the  latter  organ.  For  this  purpose,  a  full  mouth- 
ful of  the  steam  should  be  taken,  the  mouth  should  then  be  shut, 
the  nostrils  compressed  by  thumb  and  finger  of  one  hand,  and 
the  cheeks  well  expanded.     This  confined  forcible  expiration 


must  be  of  only  one  or  two  seconds'  duration,  and  must  not  be 
repeated  oftener  than  once  in  a  minute,  the  ordinary  inhaling 
going  on  in  the  intervals ;  in  other  words,  every  sixth  or  eighth 
ordinary  inhalation  should  be  intermitted  for  one  of  those  just 
described.' 

[It  is  to  be  noted  that  this  mode  of  inflating  the  Eustachian 
tube,  known  as  that  of  Valsalva,  is  occasionally  productive  of 
giddiness.  To  obviate  this  tendency  I  instruct  patients  to  throw 
the  head  back  during  the  inflation.] 

*  For  Nasal  Inhalation  an  India-rubber  nasal-piece  should  be 
placed  on  the  mouth-piece  of  the  inhaler,  or  the  orifice,  if  a  jug 
or  other  vessel  is  used,  should  be  narrowed  by  a  cone  of  card- 
board.   Insert  this  nasal-piece  into  one  nostril,  the  mouth  and 


Fig.  LYIIL— The  'Mukch'  Hospital  Inhaler. 


THERAPEUTICS  OF  THROAT  DISEASES. 


107 


the  other  nostril  being  closed ;  after  inhaling,  gently  exhale 
through  the  mouth.' 

Steam  vapour  is  often  required  in  a  room  so  that  the  patient 
may  have  the  benefit  of  a  hot  and  moist  temperature  without  the 
effort  of  inhaling.  For  this  purpose  the  Bronchitis  Kettle  is 
brought  into  requisition,  or  better  still,  the  Steam  Draught  In- 
haler of  Dr.  Robert  Lee  (Fig.  LIX.),  which  has  been  recently 
simplified  in  construction,  and  is  consequently  produced  at  less 
cost  than  formerly  by  Messrs.  Maw  and  Co. 

Dry,  Hot  Inhalations  are  of  value  in  many  cases  of  excessive 
catarrhal  secretion.     In  a  medicated  form  they  are  difficult  of 


application,  requiring  expensive  and  complicated  instruments  ;  but 
it  seems  probable  that,  in  a  large  number  of  instances,  the 
Turkish  bath  derives  much  of  its  value,  not  only  from  its  action 
on  the  sudatory  glands,  but  also  from  the  topical  action  of  the  hot, 
dry  air  upon  the  mucous  membrane  of  the  respiratory  tract.  It 
would  be  a  good  plan  if  in  all  Turkish  baths  tubes  were  arranged 
so  that  this  air  might  be  inhaled  without  the  patient  going  into 
the  hottest  or  *  radiating  '  room. 

The  reason  wh}'  certain  persons  declare  themselves  unable  to 
endure  Turkish  baths  is,  in  all  probability,  simply  because  they 
fail  to  observe  a  few  simple  precautions  which  it  may  be  well  to 
repeat  for  the  guidance  of  intending  bathers:  i.  Never  to  bathe 
at  a  less  interval  than  two  hours  after  a  meal.    2.  To  put  a  wet 


Fig.  LIX.— Lee's  Steam  Draught  Inhaler. 


io8  DISEASES  OF  THE  THROAT  AND  NOSE. 

towel  on  the  head  on  entering  the  bath  so  as  to  prevent  heat- 
stroke, a  fruitful  source  of  palpitations,  faintings,  etc.  3.  To 
have  the  body  lightly  shampooed,  and  to  take  a  glass  of  water 
if  perspiration  be  not  active.  4.  To  always  have  the  head 
washed  as  well  as  the  body.  5.  Not  to  take  a  cold  plunge  or 
swimming  bath  after,  but  to  have  a  douche— at  first  warm  and 
gradually  cooled  down— a  warm  douche  being  applied  to  the  feet 
at  the  same  time  as  the  cold,  or  immediately  after.  6.  To  take 
sufficient  time  to  cool  before  dressing,  and  during  the  cooling 
process  to  keep  the  whole  body  and  feet  also,  covered  with  a 
wrap.  7.  Not  to  take  a  bath  oftener  than  twice  a  week  in  winter, 
and  once  in  summer.  If  attention  be  paid  to  these  simple  precepts, 
there  are  few  people  to  whom  the  Turkish  bath  will  not  be  at  once 
pleasant  and  beneficial. 

Cold  Inhalations. — Having  met  with  many  instances  in  which 
the  use  of  steam  inhalations  by  persons  unable  to  remain  within 
doors  was  attended  by  liability  to  take  cold,  I  have  gradually 
narrowed  their  field  of  application,  and  for  some  years  I  made 
careful  experiments  with,  by  way  of  a  substitute,  cold  inhalations 
of  the  vapour  of  chloride  of  ammonium  produced  by  the  mixed 
fumes  of  ammonia  and  hydrochloric  acid.  I  regret  to  say  that 
their  use  has  been  attended  with  considerable  disappointment,  a 
result  which  is  abundantly  confirmed  by  hospital  colleagues  and 
many  other  fellow-workers.  The  difficulty  of  keeping  the  vapour 
absolutely  free  from  noxious  excess  of  either  acid  or  alkali  is  a 
serious  drawback,  so  that  when  the  inhalation  is  active  its  effects 
are  irritating ;  when  the  vapour  is  neutral  it  is  inert.  In  any 
case  its  usefulness  is  probably  best  exemplified  as  a  medium 
for  eucalyptol,  pinol,  etc.  Formulae  for  these  are  appended 
(Form.  41,  etc.). 

The  introduction  of  the  Oro-Nasal  Inhaler,  for  which  we  are 
primarily  indebted  to  Dr.  Coghill  of  Ventnor,  and  for  strong  ad- 
v^ocacy  to  Sir  William  Roberts,  Dr.  Burney  Yeo,  and  others,  has 
also  been  of  the  greatest  service,  as  by  its  means  vapours  can  be 
employed  without  the  risks  indicated  when  thrown  off  with 
aqueous  steam.  The  practical  value  of  all  these  forms  of  inhala- 
tions is  generally  admitted,  and  but  little  heed  need  be  taken  of 
laboratory  experiments  tending  to  minimize  their  effect  with  a 
view  of  enforcing  the  merits  of  special  inhaling  chambers. 
Simple  inhalations  of  cold  air  have  lately  been  extolled  by 
Professor  M.  Y.  Oertel  of  Munich,  in  the  treatment  of  hyper- 
3emic  conditions  of  the  respiratory  organs,  more  especially  of  the 
larynx  and  of  the  lungs,  brought  about  by  increased  activity  or 


THERAPEUTICS  OF  THROAT  DISEASES. 


o\  er-strains  of  these  organs,  as  in  public  speakers,  singers,  etc. 
In.  these  cases  inhalations  of  cold  air  exercise  a  cooling  and  re- 
freshing influence  an  the  heated  parts,  and  not  only  withdraw 
the  heat  by  exciting  the  vessels  to  energetic  contraction  and  dimin- 
ishing the  blood  contents,  but  also  avert  the  exudation  and 
tumefaction  of  the  affected  organs,  which  the  hyperaemia  may 
produce.  The  secondary  inflammatory  conditions  and  disturb- 
ances of  nutrition  gradually  set  up  in  these  persons  by  oft-repeated 
injurious  influences  will  thus  be  most  effectually  warded  off,  and 
the  development  of  diseases,  such  as  chronic  lar3^ngeal  and 
bronchial  catarrhs,  relaxation  of  the  vocal  cords,  etc.,  which  may 
be  regarded  as  professional  diseases,  will  be  delayed  as  long  as 
possible.  Non-medicated  cold  air  inhalations  are  also  of  use  in 
local  Erythematous  and  inflammatory  conditions  attended  with 
symptoms  of  heat,  dryness,  and  smarting,  such  as  erythematous 
and  acute  catarrhal  inflammation  of  the  nasal  mucous  membrane, 
and  of  that  of  the  oral  and  pharyngeal  cavity,  etc.  They  also 
bring  subjective  relief  to  the  patient  in  parenchymatous  and 
phlegmonous  inflammations  of  the  tonsils,  of  the  peritonsillar 
tissue,  of  the  uvula,  of  the  mucosa  and  sub-mucosa  of  the  buccal 
and  faucial  region  generally.  Also  in  the  deeper  regions,  such  as 
the  larynx,  trachea,  etc.,  the  cold  inhalation  acts  beneficially, 
partly  by  reason  of  its  low  temperature,  and  partly  by  its  slight 
capacity  for  moisture. 

The  apparatus  for  cold  air  inhalations  consists  essentially  of  a 
spiral  tube,  through  which  the  air  is  inspired,  fixed  into  a  suit- 
able receptacle,  and  around  which  pounded  ice  is  packed.  The 
air  which  passes  through  the  tube  prior  to  inhalation  is  thus 
reduced  in  temperature ;  but  it  is  evident  that  the  exact  degree  of 
cold  must  be  very  difficult  to  control  even  approximately. 

Compressed  Air. — The  practice  of  the  inspiration  of  compressed 
air,  and — what  is  very  like  it  in  its  effect — the  breathing  into  com- 
pressed air,  has  been  advocated  for  some  years,  and  has  of  late 
received  increased  attention,  but  principally  for  the  treatment  of 
pulmonary  affections,  attended  by  imperfect  expansion  of  the 
lung-substance.  Very  brilliant  results  are  claimed  by  Professor 
Oertel,  of  Munich,  for  this  procedure.  On  the  Continent,  pneu- 
m.atic  chambers  have  been  brought  into  use,  in  which,  by  means 
of  suitable  apparatus,  the  atmospheric  pressure  is  varied  at  the 
discretion  of  the  medical  adviser. 

Atomized  Fluid  Inhalations. — The  question  of  inhalations  of 
atomized  fluids  has  for  many  years  received  attention,  notably  by 
Hermann  Beigel,  and  in  the  well-known  book  of  Solis  Cohen. 


I  lO 


DISEASES  OF  THE  THROAT  AND  NOSE. 


More  recently  Professor  Oertel,  of  Munich,  has  treated  the 
subject  extensively.  The  time  has  gone  by  for  doubting  the 
fact  that  the  pulverized  fluid  may  pass  a  considerable  way  into 
the  air-passages  under  favourable  circumstances,  even  to  the 
liner  bronchi,  nor  can  there  be  any  reason  for  contesting  it. 
In  oral,  pharyngeal,  and  nasal  affections,  atomized  inhala- 
tions are  doubtless  of  value,  but  they  are  much  less  service- 
able than  is  generally  supposed  in  laryngeal  affections,  not  only 
because  they  are  often  opposed  to  the  principle  previously  laid 
down  of  adapting  remedies  to  the  physiological  function  of  the 
part,  but  also  because,  as  a  rule,  comparatively  little  of  the  spray 
enters  the  larynx.  The  moment  it  impinges  on  the  laryngeal 
surface  of  the  epiglottis,  the  vestibule  of  the  larynx  closes  tightly 
against  the  intruder.  The  patient  gives,  all  the  time  of  inhaling, 
short,  gaspy  coughs,  with  intervals  of  more  severe  paroxysm 
whenever  the  spasmodic  stricture  is  momentarily  relaxed.  If  a 
throat  be  examined  after  five  minutes'  use  of  an  atomized  inhalation, 
it  will  frequently  be  noticed  to  be  in  a  state  of  really  considerable 
hypersemia.  Nevertheless,  much  of  the  evil  effect  of  sprays  is 
due  to  the  form  of  instrument,  and  also  to  the  nature  of  the 
remedy  employed ;  and  there  are,  admittedly,  many  patients  who 
can  attain  sufficient  command  to  overcome  these  difficulties,  and 
to  whom  remedies  of  this  form  of  suitable  dilution  are  preferably 
indicated.  My  only  fear  is  that  their  injudicious  use,  especially 
in  the  matter  of  ingredients,  may  bring  an  occasionally  valuable 
remedy  into  universal  disrepute.  In  accordance  with  my  opinion 
of  the  limited  value  of  spray  inhalations,  the  list  of  formulae  for 
this  kind  of  remedy  is  not  much  extended  beyond  those  suitable 
for  pharyngeal  affections. 

A  valuable  method  by  which  pulverized  liquids  can  be  taken 
into  the  larynx  and  lungs  without  any  fear  of  doing  harm  by 
mechanical  irritation,  is  that  in  which  the  waters  of  Marlioz  (Aix 
en  Savoie),  Vichy,  etc.,  are  administered,  large  rooms  being 
charged  with  clouds  of  very  finely  atomized  medicated  waters. 

Sprays  may  be  used,  apart  from  purposes  of  inhalation,  to 
produce  more  local  effect  on  the  mucous  surfaces  upon  which  they 
are  directed,  especially  to  the  pharynx  and  nares.  They  may  be 
obtained  by  means  of  the  ordinary  spray  apparatus,  and  may,  by 
the  admixture  of  various  medicinal  substances,  be  made  anodyne, 
astringent,  antiseptic,  resolvent,  resorptive,  or  solvent  in  their 
action.  Pharyngeal  and  nasal  sprays  are  frequently  of  service  in 
disease  of  the  pharynx  and  naso-pharynx,  especially  where  there 
is  deposit  of  false  membrane,  as  in  diphtheria,  or  much  inspis- 


THERAPEUTICS  OF  THRO  A  T  DISEASES.  1 1 1 

sated  mucus,  as  in  ozaena,  and  in  specific  ulcerations.  In  chronic 
pharyngitis  also  the  continued  contact  of  an  astringent  spray  for 
some  minutes  is  sometimes  more  efficacious  than  topical  applica- 
tions with  the  brush,  and  is  certainly  better  if  the  remedy  is  to 
be  applied  by  the  patient  himself. 

A  very  simple  '  Throat  Spray '  is  that  of  Messrs.  Corbyn 


Fig.  LX.— Pharyngeal  Spray  Producer. 


(Fig.  LX.),  the  vulcanite  spatula,  which  is  a  part  of  the  ap- 
paratus, acting  well  both  in  keeping  the  tongue  down  and  in 


Fig.  LXI.— Double  Handball  Throat  Spray  Producer. 


directing  the  stream  of  spray  to  the  back  of  the  fauces.  Another 
form  of  this  spray  with  double  handball,  by  which  the  steam  can 
be  made  continuous,  or  can  be  broken,  is  that  depicted  in  Fig. 
LXI.  This  is  the  form  used  by  me  when  applying  cocaine  as 
a  sedative  to  the  nose  or  throat  before  operation.  An  advantage 
of  the  handball  spray  is  that  it  is  non-continuous.  The  spray 
may  therefore  be  projected  simultaneously  with  the  act  of  inspira- 
tion, and  arrested  during  ex-spiration,  whereas,  in  Siegle's  (Fig. 
LXIL),  and  other  continuous  atomizing  apparatus,  the  spray 
plays  the  whole  time,  and  thus  probably  increases  the  irritation 
which  has  been  alluded  to  as  a  not  infrequent  effect  of  such 


112 


DISEASES  OF  THE  THROAT  AND  NOSE. 


measures.  Nevertheless  the  steanJ  sprays  are  in  most  cases  prefer- 
able, because  the  atomized  vapour  is  somewhat  warmed,  which  is 
often  a  desideratum.    The  best  are  those  of  Siegle,  as  improved 


Fig.  LXII.— An  Improvement  of  Siegle's  Steam  Spray  Inhaler, 


by  Krohne,  and  the  Universal  Atomizer  of  Codman  and  Shurtleff, 
of  Boston,  U.S.A. 

When  such  diseases  as  diphtheria  have  extended  into  the  larynx 
and  trachea,  applications  of  the  character  of  a  spray  are  better 


Fig.  LXIIL— Laryngeal  Syringe. 

Cy  pressure  of  the  ringer  on  the  india-rubber-covered  receptacle  on  the  handle,  the 
amount  of  fluid  to  be  drawn  into  the  tube,  or  to  be  discharged,  can  be  regulated. 


applied  directly  by  the  surgeon  with  one  of  Tiirck's  or  Schroetter's 
laryngeal  syringes  (Fig.  LXIIL),  a  procedure  which  is,  of  course, 
not  capable  of  self-adoption  ;  and  better  for  direct  application  by 
those  practising  as  specialists,  is  the  Compressed  Air  Pump 
(Fig.  LXIV.)  with  separate  tubes  for  the  various  solutions. 


THERAPEUTICS  OF  THROAT  DISEASES.  113 

Oertel  recommends  the  employment  of  iced  water  as  a  spray 
in  hypersemic  conditions  of  the  upper  part  of  the  respiratory 
organs,  where  the  membranes  are  erythematous  and  dry,  as  in 
catarrhal  and  phlegmonous  inflammations,  either  idiopathic  or 
symptomatic.  Also  in  chronic  catarrhs  attended  with  heat  and 
dryness,  in  so-called  pharyngitis  sicca,  it  is  invaluable.  Seitz  has 
also  used  it  extensively  in  the  treatment  of  angina  tonsillaris.  In 
cases  where  ropy  secretion,  difficult  of  expectoration,  adheres  to 
the  mucous  membranes,  especially  to  the  posterior  pharyngeal 
wall,  as  in  many  forms  of  pharyngeal  catarrh,  a  partial  liquefac- 
tion of  such  masses  may  be  at  once  effected  by  this  means,  anc? 
ihus  expectoration  facilitated. 


Fig.  LXIV.— Pneumatic  Pump  and  Spray  Tube. 


Sprays  so  applied  by  pneumatic  pressure,  and  by  aid  of  the 
mirror,  have  long  been  employed  in  America  in  preference  to  topical 
applications  by  means  of  brushes,  etc.,  on  the  ground  that  less 
irritation  of  the  mucous  membrane  is  thus  produced.  They  have 
my  unqualified  approval  for  all  cases  where  a  free  general  dis- 
tribution of  a  topical  remedy  is  desired,  and  where  the  surface  is 
unbroken,  but  for  hmited  ulcerations  and  new-growths  I  feel 

8 


114 


DISEASES  OF  THE  THROAT  AND  NOSE. 


satisfied  that  better  results  may  be  obtained  by  means  of  solu- 
tions accurately  applied  to  the  diseased  part  by  some  form  of 
brush,  the  action  of  the  medicinal  agent  being  thus  strictly 
localized.  Moreover,  stronger  remedies  may  be  used  in  this  way 
than  by  means  of  the  spray;  for  the  stronger  the  agent  we  employ 
the  more  necessary  it  becomes  to  restrict  its  action  to  the  diseased 
area,  and  this  is  difficult  of  achievement  otherwise  than  by  a 
brush  or  analogous  instrument. 

The  Uses  of  Inhalations. — The  varieties  of  inhalations  just 
described  are  employed  for  their  action  as  antiseptics,  antispas- 
modics, astringents,  haemostatics,  resolvents,  sedatives,  and 
stimulants  (capillary,  mucous,  and  salivary).  The  best  time  for 
administering  inhalations  is,  as  a  rule,  before  meals.  The  in- 
halation should  not  be  taken  rapidly ;  about  six  inspirations  in 
a  minute  being  quite  sufficient.  When  the  patient  is  using  hot 
vapour  inhalations,  it  will,  of  course,  be  necessary  for  him  to 
take  precautions  against  catching  cold ;  and  for  this  purpose  it 
is  advisable  not  to  go  out  of  doors  within  half  an  hour  of  taking 
such  inhalation.  As  already  noted,  even  with  such  precautions 
steam  inhalations  are  not  unattended  by  reactionary  risks.  In 
the  case  of  cold  inhalations,  however,  the  patient  may  go  out  at 
once  with  impunity,  and  it  will  even  be  found,  in  some  cases,  that 
the  use  of  a  cold  inhalation,  just  before  going  out,  will  procure  for 
the  patient  an  immunity  trom  catarrh  which  he  had  not  previously 
enjoyed. 

In  the  administration  of  sedative  inhalations  very  great  care 
must  be  exercised,  some  volatile  sedatives,  when  mixed  with 
steam,  having  a  more  powerful  action  than  under  other  circum- 
stances. For  instance,  as  I  many  years  ago  pointed  out,  the 
inhalation  of  even  one  drop  of  chloroform  in  a  pint  of  water  at 
150°  Fahr.  will  occasionally  produce  giddiness  and  nausea.  A 
similar  caution  applies  to  nitrite  of  amyl  and  aldehyde,  several 
drops  of  which  may,  however,  be  taken  from  blotting-paper  with- 
out producing  any  toxic  effect. 

Fumigations,  or  Fuming  Inhalations. — In  this  form  the  pro- 
ducts of  carboniferous  combustion  are  inhaled.  These  inhalations 
are  usually  produced  by  the  ignition  of  unsized  paper  saturated 
with  nitre  or  some  other  substance.  The  dense  fumes  which  thus 
arise  are  inhaled.  The  papers  may  be  medicated  with  various 
stimulating  and  antispasmodic  ingredients.  The  inhalation  can 
be  made  from  a  saucer,  or  preferably  from  an  old-fashioned 
cylindrical  earthenware  spill  vase. 

In  certain  cases  of  tertiary  syphihtic  laryngitis  and  tracheitis. 


THERAPEUTICS  OF  THROAT  DISEASES. 


115 


as  well  as  on  general  principles  in  secondary  syphilis,  mercurial 
fumigations,  administered  in  the  method  recommended  by  Mr. 
Henry  Lee,  or  by  means  of  an  ingenious  apparatus  devised  by  my 
former  colleague,  Mr.  Francis  Hamilton  (Fig.  LXVHI.),  and 
manufactured  for  him  by  Messrs.  Krohne  and  Co.,  will  be  most 
beneficial  in  effect  on  the  local  condition. 

The  illustration  almost  explains  the  instrument  without  further 
description.  It  is  only  to  be  noted  that  A  is  a  lamp  for  subHming 
the  calomel  or  other  drug  used,  which  is  placed  in  a  small  drawer 
B  ;  the  fumes  pass  into  the  subHmer  C,  and  make  their  exit  with 
steam  from  the  tube  D  connected  with  the  water-boiler  G.  The 
whole  of  the  subliming  apparatus  can  be  removed,  and  a  Siegle 
tube  K  substituted  at  D,  the  long  limb  being  placed  in  a  bottle 


Fig.  LXV.— Hamilton's  Mercurial  Fumigator  and  Atomizing  Inhaler. 

containing  the  medicated  solution  to  rest  on  the  drawer  B.  The 
apparatus  then  answers  all  the  purposes  of  an  atomizing  inhaler. 
The  following  are  some  of  the  precautions  necessary  in  the 
administration  of  mercurial  fumigations  : 

Firstly,  the  calomel  should  be  the  resiihliined  preparation,  and 
not  such  as  is  ordinarily  used  internally  in  medicine.  This  is 
important,  as  the  ordinary  calomel  is  often  very  irritating  for 
inhalation,  owing  to  the  impurities  which  it  contains. 

Secondly,  the  quantity  of  calomel  used  should  at  first  only  be 
small,  about  two  to  five  grains  ;  it  can  afterwards  be  increased  to 
ten  grains  if  necessary. 

Thirdly,  the  patient  should  be  cautioned  to  never  inhale  more 
than  he  can  stand  without  much  coughing,  and  this  is  especially  the 
case  on  first  employment,  when  it  is  as  well  that  he  should  not  take 
more  than  two,  three,  or  four  inspirations ;  after  a  day  or  two,  he 
will  be  able  to  tolerate  it  much  better.    In  using  the  instrument, 


it6  diseases  of  THE  THROAT  AND  NOSE. 


the  second  lamp  A  should  not  be  lighted  until  the  steam  is  coming 
off  freely  from  the  boiler,  as  otherwise  a  dry  instead  of  a  moist 
inhalation  would  be  emitted,  and  this  is  as  a  rule  far  more 
irritating. 

It  will  be  seen  at  once  that  the  apparatus  can  be  used  as  a 
local  fumigator  for  any  part  of  the  body— for  ulcer  of  the  leg 
— as  well  as  for  the  larynx. 

External  Applications  to  the  throat  are  frequently  of  great 
value,  and  consist  of  compresses,  poultices,  pigments,  etc. 

The  following  are  the  printed  directions  given  to  my  hospital 
patients  for  making  a  wet  (laryngeal)  compress  : 

*'  Take  a  piece  of  Hnen  the  size  of  this  piece  of  paper  (ordinary 
note,  7  in.  by  5  in.),  or  of  Hnt  half  the  size.  In  the  case  of  linen, 
fold  into  four  ;  or  of  lint,  fold  twice.  Saturate  the  same  with  cold 
water,  or  very  dilute  iodine  solution  as  prescribed,  and  place  it 
over  the  front  of  the  throat,  in  the  situation  of  the  Adam's  apple. 
Cover  with  a  piece  of  oil  silk,  waxed  paper,  or  other  waterproof 
material,  which  must  be  at  least  half  an  inch  larger  than  the  hnt, 
in  every  direction.  By  lining  the  oiled  silk  with  flannel,  greater 
adaptability  is  obtained.  Secure  by  means  of  a  handkerchief  tied 
twice  round  the  neck.  A  compress  applied  at  night  should  not 
be  changed  until  the  morning,  when  the  neck  should  be  well 
sluiced  with  cold  water,  and  rubbed  with  a  towel.'  Compresses 
are  made  in  convenient  form  by  Roberts  of  Bond  Street.  Those 
for  the  tonsils  would  naturally  be  required  of  a  larger  size,  and  the 
direction  then  is  that  the  compress  should  bo  of  dimensions  to 
extend  from  angle  to  angle  of  the  jaw. 

Authorities  differ  as  to  whether  the  covering  is  to  be  im- 
permeably  water-tight  or  simply  a  dry  cloth.  My  own  ex- 
perience is  in  favour  of  water-proof,  with  the  precaution  of 
douching  with  cold  water  and  friction  on  removal  of  the 
compress.  Cold  moist  applications  thus  employed  are  serviceable 
in  promoting  resolution  in  recent  congestions  and  inflammations 
of  a  subacute  type  ;  but  for  more  active  inflammations  or  for  the 
ripening  of  a  suppuration,  the  older-fashioned  cataplasm  is  pre- 
ferably indicated.  Of  poultices  the  best  forms  are  Dr.  Lelievre's 
Iceland  moss  poultice,  the  ordinary  linseed  or  linseed  and  mustard 
poultice,  and  spongio-piline. 

I  have,  however,  found  that  external  applications  of  dry  cold 
are  generally  preferable  to  heat  in  most  cases  of  inflammatory 
disease  of  the  throat.  Either  cold  or  heat  can  be  appHed 
continuously  by  means  of  '  Leiter's  Temperature  Regulators' 
(Fig.  LXVI.),  and  a  lengthened  experience  convinces  me  that  we 
have  in  them  very  valuable  agents. 


THERAPEUTICS  OF  THROAT  DISEASES. 


117 


The:e  is,  of  course,  nothing  new  in  the  application  of  cold  for 
the  reduction  of  inflammation,  but  hitherto  the  difficulties  and 
inconvenience  of  applying  either  dry  cold  or  heat  with  constancy 
of  temperature  in  the  region  of  the  throat,  or  indeed  elsewhere, 
have  been  so  great  that  this  method  is  practically  a  novelty. 
The  introduction  of  cold  apphcations  to  the  throat  in  preference 
to  warm  is  also,  I  believe,  a  therapeutic  innovation. 

For  those  not  familiar  with  the  apparatus  a  brief  description  is 
requisite. 

It  consists  of  a  simple  leaden  coil  of  narrow  calibre,  and  made 
of  flexible  metal  tubing,  kept  in  position  by  pieces  of  webbing, 


FiG.  L!!'vVI.  — Letter's  Pliable  Metal  Temperature  Regulator,  for  coNTiNrous 
Application  of  Vv^armth  or  Cold  to  Different  Parts  of  the  Human  Body. 

Sp.  The  spiral  regulator  applied  to  the  throat  with  the  ingress  tube  (2^)  in  the  supplying 
vessel,  and  the  egress  tube  {as)  going  out  of  the  drawing.  Z.  Lamp  for  warming  the 
water  if  hot  applications  are  desired.    T.  Thermometer. 


and  having  connected  at  each  terminal  a  flexible  rubber  conduit 
with  leaden  weights  at  the  end,  similar  to  that  employed  in  the 
syphon  nasal  douche.  By  placing  one  terminal  tube  in  a  vessel 
of  water,  slightly  above  the  patient's  head,  and  making  suction 
on  the  lower  tube  syphon  action  is  at  once  established  ;  this  lower 
or  egress  tube  is  placed  in  another  jug  acting  as  a  receiving 
vessel  on  the  floor.    When  the  lower  vessel  is  nearly  full,  the 


ii8  DISEASES  OF  THE  THROAT  AND  NOSE. 

position  of  the  two  vessels  may  be  reversed  ;  and  by  this  repeated 
changing,  as  required,  a  continuous  flow  of  water  through  the 
coil  is  maintained  for  any  length  of  time  without  even  changing 
the  water.  For  cold  applications  a  temperature  of  60°  to  68°  Fahr. 
is  often  sufficient  to  abstract  heat.  That  of  50°  to  ss"*  gives  an 
effect  equal  to  that  of  ice  in  icebags.  If  a  temperature  of  2>S''  to 
40**  be  employed,  complete  anaesthesia  can  be  produced.  Even 
the  temperature  of  50°  cannot  long  be  endured,  and  requires  a 
layer  of  flannel  between  the  coil  and  the  applied  surface.  In 
case  hot  applications  are  required,  an  ingenious  adaptation  similar 
to  that  used  for  bath  purposes,  and  known  as  the  *  Geyser/  will 
keep  up  the  temperature  to  the  degree  required,  which  is  indicated 
by  a  thermometer  supplied  with  the  apparatus. 

This  method  of  applying  cold  has  been  principally  used  by  me 
in  cases  of  tonsillitis,  and  in  all  the  relief  experienced  was  im- 
mediate and  marked.  It  is  now  always  the  first  prescribed  step 
in  the  way  of  local  measures.  In  a  case  of  acute  inflammation  of 
the  fauces,  the  result  of  inhalation  of  sewage  gas,  the  effect  was 
equally  satisfactory.  I  have  also  employed  it  for  the  relief  of  pain 
and  promotion  of  rapid  healing  after  removal  of  tonsils,  and  in 
several  cases  of  cancer  of  the  throat.  For  this  last  condition, 
however,  greater  comfort  and  increased  ease  in  deglutition  are 
generally  derived  from  application  of  heat  by  the  same  method. 
Again,  I  have  thus  applied  cold  over  an  enlarged  thyroid  gland, 
with  a  result  of  perceptible  diminution  of  the  swelling,  and  I  would 
recommend  it  in  what  one  may  call  acute  congestion  of  this 
region.  This  method  was  also  advocated  in  my  paper  on  the 
local  treatment  of  diphtheria,  before  the  International  Congress 
in  London  (1881),  but  I  had  not  at  that  time  met  with  a  case  in 
which  to  test  its  efficacy.  Later  experience  in  several  instances 
has  more  than  confirmed  my  favourable  anticipations.  In  in- 
flammation of  the  larynx,  of  both  mild  and  severe  type,  continuous 
cold  is  of  marked  value.  Very  striking  and  indeed  complete  relief 
was  afforded  in  a  case  of  traumatic  oedema  of  the  larynx  (due  to 
the  irritation  of  a  piece  of  rabbit  bone,  accidentally  swallowed) 
which  I  saw  some  two  years  ago  in  consultation  with  Mr.  Hobson 
of  Hemel  Hempstead.  In  this  instance  painful  and  continuous 
spasm  was  at  once  relieved  on  application  of  the  coil,  but  I  was 
asked  to  pass  the  night  in  the  house.  A  relapse  occurred  about 
2  a.m.  of  such  severity  as  to  justify  my  being  called  from  my 
bed  ;  when  it  was  discovered  that  the  ingress  tube  was  not  in  the 
water,  and  consequently  the  flow  had  ceased.  On  correction  of 
this  defect  and  renewal  of  the  flow,  the  spasm  was  again  immedi- 
ately relieved,  and  did  not  return. 


THERAPEUTICS  OF  THROAT  DISEASES. 


The  advantages  justly  claimed  for  Leiter's  regulators  are  pre- 
eminently manifested  when  applied  to  the  neighbourhood  of  the 
air- passages,  and  they  are  as  follows  : 

1.  The  effect  is  strictly  local. 

2.  The  temperature  is  constant ;  when  warm,  applications  do 
not  become  cold,  nor  cold  applications  warm. 

3.  Moisture,  with  all  its  attendant  inconvenience,  is  not 
necessary,  but  if  indicated  can  be  applied  by  this  method,  the 
required  temperature  being  maintained. 

4.  They  are  cleanly,  light,  and  not  liable  to  get  out  of  order. 

5.  Ice,  often  so  difficult  to  obtain,  is  not  required,  the  tempera- 
ture of  ordinary  pump-water  being  quite  cold  enough. 

6.  Lastly,  it  is  not  out  of  place  to  mention  that  the  apparatus 
is  so  cheap,  and  capable,  moreover,  of  such  diverse  application, 
that  (unlike  many  other  novelties  in  instrumental  therapeutics) 
there  need  be  no  hesitation  in  urging  its  general  adoption. 

Of  pigments  for  external  application  the  best  for  purposes  of 
counter-irritation  and  absorption  (the  former  now  rarely  employed 
by  me)  are  the  compound  liniment  of  mustard,  the  liniment, 
ointment,  or  the  tincture  of  iodine  of  the  British  Pharmacopoeia : 
one  coat  of  the  latter  may  be  applied  every  night  with  great 
advantage  in  chronic  laryngitis,  and  the  stain  is  generally  gone 
before  morning.  The  pigmentum  chloralis  et  camphorse  (Form. 
57)  will  also  be  found  of  great  value  as  a  sedative  in  neuralgic 
affections,  and  in  painful  diseases  of  the  cartilages  or  interior  of 
the  larynx.  Strong  counter-irritation  by  blistering  of  the  throat 
on  account  of  internal  maladies  has  been  found  rather  harmful 
than  beneficial  in  my  own  experience.  *  Mustard  leaves  '  are  not 
recommended;  some,  which  have  been  procured  from  the  original 
establishment,  have  appeared  to  contain  an  irritant  ingredient 
foreign  to  the  mustard-seed,  which  renders  them  very  objection- 
able. 

Douches  or  CoUunaria. — A  rough-and-ready,  and,  consequently, 
a  not  always  satisfactory,  method  of  washing  the  cavities  of  the 
throat  and  nose,  besides  gargling,  is  that  of  '  sniffing '  fluid  up 
the  nostrils  from  the  hollow  of  the  hand  or  from  a  nasal  bath ; 
but  special  instrumental  methods  are  by  preference  to  be  em- 
ployed. These  are  the  anterior  nasal  douche,  the  posterior  nasal 
douche,  Tiirck's  laryngeal  douche,  already  mentioned,  and  the 
oesophageal  douche.  The  last-named  is  but  little  employed,  and 
cannot  be  recommended,  owing  to  the  fact  that  any  fluids  applied 
to  the  oesophagus  are  very  quickly  absorbed  or  washed  away. 

The  action  of  the  anterior  nasal  douche  on  the  syphon  principle 


120 


DISEASES  OF  THE  THROAT  AND  NOSE. 


(Fig  LXVII )  is  based  upon  the  fact  that  when  breathing  Is  carried 
on  with  the  mouth  open,  the  palate  becomes  approximated  to  the 
pharynx,  and  a  current  of  fluid  sent  through  one  nostril  will  issue 


Fig.  LXVII. — The  Anterior  Syphon  Nasal  Douche,    a.  Soft  Rubber  Nasal 
Piece,  employed  by  Author  for  Douche  and  Politzer  Bag. 

N.B, — The  elbow  I,  and  the  nasal  piece  are  also  made  of  glass,  and  offer  similar 
advantages  as  in  the  case  of  the  insufflator. 

from  the  other.  Instead  of  the  reservoir  furnished  with  ordinary 
forms  of  douche,  Harrison  Allen  has  devised  an  excellent  instru- 
ment (Fig.  LXVIII.).  This  consists  of  a  stopper  to  be  adapted  to 


Fig.  LXVIII. — Harrison  Allen's  Apparatus  for  Anterior  Nasal  Douche. 

an  ordinary  bottle,  and  so  made,  that  when  the  bottle  is  inverted, 
the  liquid  will  pass  down  the  tube,  while  air  enters  through 
another  smaller  tube  in  such  a  way  as  to  form  no  interruption  to 
the  flow  of  the  fluid.  On  account  of  its  cheapness  and  portability. 


THERAPEUTICS  OF  THROAT  DISEASES, 


121 


as  well  as  on  the  absence  of  force  in  the  stream,  this  form  of 
douche  is  one  that  may  be  safely  recommended.  The  effect  pro- 
duced by  the  use  of  the  anterior  nasal  douche,  in  any  form, 
however,  is  not  very  thorough,  and  it  is  now  almost  superseded  in 


Figs.  LXIX.,  LXX.,  LXXI.  and  LXXIL— Posterior  Nasal  Syringes,  as  used 

BY  THE  Author. 

Nos.  I  and  2.  These  forms  are  the  best  for  a  practitioner  to  employ.  No.  3  shows  the 
stream  as  it  comes  from  the  different  points  ;  Nos.  i  and  2  and  4  are  drawn  half  dimen- 
sions ;  No.  3  is  of  full  size.  The  instrument  is  made  of  vulcanite,  and  the  exact  curve 
of  the  tube  can  be  altered  at  will  by  well  oiling  it  and  then  heating  it  over  a  spirit-lamp. 
Recently  some  tubes  have  been  made  of  virgin  silver,  which  can  be  readily  adapted  to 
any  curve  or  angle.  No.  4  shows  the  same  syringe  more  conveniently  adapted  for  self- 
use. 

my  practice  by  the  posterior  nasal  douche.  Besides  the  inefficacy  of 
the  anterior  nasal  douche,  it  is,  in  some  cases,  absolutely  injurious. 
Dr.  Roosa  has  brought  overwhelming  evidence  in  support  of  his 
statement  that  the  anterior  nasal  douche,  in  a  considerable 


122 


DISEASES  OE  THE  THROAT  AND  NOSE, 


number  of  cases,  causes  acute  inflammation  of  the  middle  ear; 
and  his  experience  has  been  amply  confirmed  by  myself. 

This  objection  does  not  seem,  according  to  present  experience, 
to  obtain  with  respect  to  the  use  of  the  posterior  nasal  douche 
(Figs.  LXIX.,  LXX.,  LXXI.  and  LXXII.),  which  is,  besides, 
more  effectual  in  clearing  the  post-nasal  and  nasal  cavities  of 
abnormal  secretion. 

Neither  of  these  means  are,  howeiver,  always  entirely  efficient 


Fig.  LXXIII.— The  'Lefferts'  Coarse  Spray  (Two-fifths  Measurement). 
a.  The  vulcanite  tube,  containing  the  atomizing  tube  (a!),    b.  The  nasal  piece,  full  size. 

m  removing  nasal  incrustations  in  chronic  atrophic  rhinitis 
(ozaena)  and  the  '  Coarse  Nasal  Spray'  of  Lefferts  (Fig.  LXXIII.) 
is  a  valuable  addition  for  this  purpose  to  our  therapeutic  arma- 
mentorium.  This  apparatus  is  made  in  this  country  by  Krohne 
and  Co.,  who  have,  at  my  suggestion,  graduated  the  bottle.  The 
following  are  the  printed  directions,  modified  from  Lefferts,  pasted 
on  the  lid  of  each  box  containing  the  instrument : 

I.  Dilute  the  medicated  fluid  with  the  prescribed  proportion  of 
hot  water,  so  that  the  solution  is  about  a  temperature  of  95" 
(blood  heat) 


THERAPEUTICS  OF  THROAT  DISEASES. 


I2i 


2.  Stand  erect,  and  incline  the  head  very  slightly  forward  over 
a  toilet  basin. 

3.  Introduce  the  conical  nozzle  of  the  apparatus  into  one  nostril, 
and  far  enough  to  close  it  perfectly,  holding  the  horizontal  tube  ol 
the  apparatus  directly  outwards  from  the  face. 

4.  Open  the  mouth  widely  and  breathe  gently  but  quickly 
through  it  in  a  snoring  manner ;  avoiding  carefully  all  attempts  at 
speaking,  swallowing,  or  coughing. 

5.  Hold  the  end  ball  of  the  apparatus  firmly  in  the  right  hand 
(the  left  holding  the  bottle),  and  work  it  briskly  until  the  spray  of 
medicated  fluid,  which  should  be  felt  at  once  to  enter  the  nasal 
passage,  has  passed  around  it  and  appears  at  the  opposite  nostril. 
At  the  moment  that  the  fluid  passes  into  the  upper  part  of  the 


Fig.  LXXIV.— Author's  Nasal  Hand  Syringe  (Half  Measurements). 

throat  from  the  nostril  which  is  being  operated  on,  a  desire  to 
swallow  will  be  experienced  ;  resist  it,  and  the  next  second  the 
fluid  passes  forward. 

6.  Having  used  half  the  fluid,  remove  the  apparatus,  and  repeat 
the  operation  upon  the  opposite  nostril. 

7.  Before  removing,  allow  the  ball  to  collapse,  so  that  all  the 
air  may  be  pressed  out.  On  removal  of  the  nozzle,  blow  the  nose 
gently — never  vigorously.         "      _        •  :  _ 

Should  the  nostrils  not  be  entirely  cleansed  by  these  means,  it 
is  recommended  that  the  patient  use,  a  few  minutes  after,  a  warm 
saline  douche  of  two  ounces  by  means  of  the  anterior  nasal 


124 


DISEASES  OF  THE  THROAT  AND  NOSE, 


syringe  which  I  designed  for  the  purpose  (Fig.  LXXIV.),  an 
instrument  which  can  be  easily  substituted  by  covering  the  glass 
nozzle  of  a  Gilbertson  two-ounce  syringe  with  a  soft  rubber  teat, 
the  hole  of  which  has  been  enlarged.  Recently  I  have  given 
directions  that  all  terminals  for  introduction  into  the  nostrils 
are  to  be  made  oval,  the  shape  of  the  nostril,  instead  of  round. 
This  ensures  more  perfect  introduction  and  less  risk  of  distortion 
of  the  nasal  orifice  on  long-continued  use  of  the  instrument. 

Douches  are  generally  used  as  antiseptic  and  deobstruent  irri- 
gations, and  occasionally  also  as  haemostatics. 

Tampons  of  wool,  medicated  with  iodoform,  hamamelis,  and 
other  drugs,  and  bougies  made  of  gelato-glycerine  (the  Gossypia 
and  Buginariae  of  the  Throat  Hospital  Pharmacopctia),  have  not, 
on  trial,  justified  their  recommendation.  Ointment  and  thickened 
fluid  solutions,  made  with  wool-brushes  of  varying  sizes,  according 
to  the  amount  of  pressure  and  dilatation  required,  are  found 
by  my  colleagues  and  myself  to  answer  all  purposes  claimed  by 
the  newly  introduced  remedies  under  the  above  fanciful  titles. 

Pigments  for  Internal  Application. — These  can  only  be  applied 
by  the  patients  themselves  to  the  pharynx  and  anterior — by  some 
to  the  posterior — nares.  For  application  to  the  pharynx  aqueous 
solutions  are  the  best.  If  it  be  desired  that  the  substance  should 
remain  long  in  contact  with  the  part,  it  will  be  found  well  to 
mix  it  with  bismuth  and  starch  or  mucilage,  or  to  add  a  little 
glycerine.  Undiluted  preparations  of  glycerine  are  very  irritating 
in  all  catarrhal  conditions  of  mucous  passages,  owing  to  the 
peculiar  attraction  of  glycerine  for  water.  For  applications  to 
the  nares,  vaseline  or  lanoline  will  be  found  very  useful  media; 
these  substances  being  absorbed  by  the  nasal  mucous  membrane, 
while  oils  and  cerates  are  not. 

All  pigments  should  be  applied  with  some  form  of  brush.  It 
is,  as  a  rule,  much  more  difficult  to  apply  solutions  accurately 
with  a  sponge ;  though  man}^  excellent  practitioners  use  this  last 
material  secured  in  a  suitable  holder,  employing  a  fresh  morsel 
for  each  case  (Figs.  LXXV.,  LXXVI.,  and  LXXVIL).  Dr. 
Smyly,  of  Dublin,  instead  of  a  brush  of  hair,  uses  pieces  of 
aluminium  suitably  bent  and  fixed  in  a  wooden  handle;  round 
the  roughened  ends  of  the  metal  he  twists  a  piece  of  absorbent 
cotton-wool,  using  a  fresh  piece  for  each  patient  (Fig.  LXXVIIL). 
This  material  is  very  suitable  for  pharyngeal,  and  especially  for 
nasal  applications,  and,  both  on  aesthetic  principles  and  as  a  pre- 
caution against  the  risk  of  contagion,  is  preferable  for  general 
use,  whether  in  hospital  or  private  practice,  to  a  brush  employed 


THERAPEUTICS  OF  THROAT  DISEASES.  125 

repeatedly  and  indiscriminately  for  several  individuals.  Having 
more  than  once  witnessed  the  unfortunate  accident  of  fracture  of 
the  aluminium  at  its  juncture  with  the  handle,  I  now  employ  only 

Fig.  LXXV. 


Sponge-Holders  (Two-tkirds  Measurements), 

Fig.  LXXVI.  represents  the  instrument  open,  and  Fig.  LXXVII.  the  same  closed  by  the 
catch  ;c  so  as  to  secure  the  sponge. 


whalebone  or  vulcanite  wool-holders  made  m  one  piece  ;  and  to 
avoid  the  possible  risk  of  the  wool  dropping  off,  the  end  is  per- 
forated, and  the  wool  is  threaded  in  the  holders  to  be  used  for 


Fig.  LXXVIII.— Smyly's  Cotton-wool  Brush  (Half  Measurements). 


laryngeal  application  as  shown  in  Fig.  LXXIX.,  in  which  are 
also  illustrated  the  varying  shapes  of  the  wool.  In  the  case  of 
children,  where  the  use  of  the  brush,  or  of  any  instrument,  is  a 


126 


DISEASES  OF  THE  THROAT  AND  NOSE. 


matter  of  difficulty,  it  will  be  found  a  good  plan  to  wrap  a  piece 
of  lint  round  the  index-finger,  as  this  can  be  often  inserted  where 
a  brush  or  a  sponge  could  not. 

Pigments  may  be  used  for  their  antiseptic,  astringent,  sedative, 
solvent,  or  stimulant  action. 

Class  U.  includes  all  intra-laryngeal  operations,  some  of  which 


FiQ.  LXXIX. — Terminals  of  Cotton-wool  Brushls  (Full  Size). 

I.  Mode  of  threading  cotton-wool  into  whale  bone  or  vulcanite  holder.    2.  Square-ended 
cotton- wool  brush.    3.  The  same  pointed.    4.  Post-nasal  cotton- wool  brush. 

have  already  received  notice.  These,  in  my  own  practice,  are 
mostly  confined  to  fluid  applications  with  a  brush,  solid  appUca- 
tions  with  a  porte-caustique,  insufflations,  the  galvano-cautery, 
and  the  use  of  surgical  instruments  of  various  kinds.  The  direct 
topical  application  of  laryngeal  sprays,  as  advised  by  Lefferts  and 
other  American  authors,  would  also  come  under  this  heading. 


Fig.  LXXX  — Author's  Laryngeal  Brush  (Half  Measurements). 


Whenever  it  is  necessary  to  apply  solutions  low  down  into  the 
larynx,  care  should  be  exercised  not  to  overcharge  the  brushes. 
In  the  case  of  ulceration,  or  where  a  local  sedative  effect  is  desired 
to  be  prolonged,  the  fluid  may  be  thickened,  as  already  described. 

With  regard  to  the  best  form  of  instrument  for  making  appHca- 
tions  to  the  larynx,  laryngologists  differ  in  opinion,  and  each 


3 


THERAPEUTICS  OF  THROAT  DISEASES. 


127 


practitioner  will  doubtless  suit  his  own  fancy  in  this  respect. 
The  shape  of  the  brush  employed,  for  the  most  part,  in  my  own 
practice  (Fig.  LXXX.),  is  that  of  a  curved  right  angle,  less  square 
than  those  usually  recommended.  The  great  fault  of  most 
brushes  sold  by  instrument-makers  is  that  they  are  too  large. 
Every  brush  for  the  larynx  should  be  capable  of  being  drawn  to  z 
fine  point,  like  a  water-colour  painting-brush.  The  size  should 
be  that  known  to  artists'  colourmen  as  'goose-quill.'  As  just 
indicated,  hair  brushes  are  almost  entirely  superseded  in  my 
practice,  both  public  and  private,  by  those  of  absorbent  cotton- 
wool, which  can,  of  course,  be  made  of  any  size  or  shape  necessary 
to  the  requirements  of  individual  cases. 

Insufflations  of  powders  may  be  conveniently  administered 
by  the  mstrument  figured  below  (Fig.  LXXXI.)  ;  but  for  more 
accurate  application,  and  especially  in  laryngeal  and  oesophageal 
disease,  the  insufflator  of  Labiersky  (Fig.  LXXXI  I.),  sold  by 
Krohne,  is  far  preferable.    Insufflations  have  been  much  in  vogue 


a  h 


Fig.  LXXXI. — Vulcanite  Insufflator  for  applying  Medicated  Powders  to 

THE  Throat. 

The  portion  of  the  tube  a  slips  up  and  discloses  a  receptacle,  b,  for  the  powder.  When 
charged,  the  telescope  part,  a,  can  be  slid  back.  N.B. — This  instrument  is  now  made 
in  glass,  the  transparency  of  which  is  convenient  in  case  of  obstruction  ;  it  is  also  more 
easily  cleaned. 

of  late  years  for  nasal,  pharyngeal,  and  laryngeal  diseases.  I  have 
given  them  a  fair  trial,  and  find  that — i.  In  nasal  diseases,  taken 
as  snuffs,  they  are  as  useless  as  the  unphysiological  ground  on 
which  they  are  recommended  would  lead  the  practitioner  to 
expect;  for  if  there  be  excess  of  thin  rhinal  secretion,  it  is  by 
powders  made  thick ;  if  the  secretion  be  thick,  it  is  made  thicker. 
In  any  case  the  orifices  of  the  glands  are  obstructed,  and  though 
the  result  may  be  less  discharge,  it  is  at  the  expense  of  increase 
of  inflammation  of  the  mucous  membrane,  and  probably  of  in- 
crustations leading  to  erosion  and  ulceration.  2.  In  the  pharynx 
insufflations  of  iodciform  and  other  remedies  are  sometimes  service- 
able in  painful  ulcerations,  though  they  are  not  often  used  in  my 
own  practice.  The  only  conditions  in  which  I  have  found  powders 
to  be  really  of  betiefi-t  are  tuberculosis  thickening  and  ulceration 
of  the  epiglottis,  and  in  malignant  diseases.    In  these  cases  direct 


28 


DISEASES  OF  THE  THROAT  AND  NOSE. 


applications  by  means  of  an  insufflation  of  a  medium  of  bismuth, 
starch  or  tragacanth,  containing  morphia  in  varying  proportions, 
are  attended  with  the  best  results,  and  the  remedy  in  this  form 
can  be  better  applied  by  the  patient  than  can  a  liquid.  The  latter 
form  is,  however,  on  many  accounts,  preferable  when  the  prac- 
titioner makes  the  application,  as  the  remedy  can  be  applied 


Fig.  LXXXII.— Labiersky's  Laryngeal  Insufflator  with  various  Terminals. 

The  instrument  is  worked  by  pressure  on  the  spring  (a),  the  ball  having  been  previously 

inflated. 

with  far  greater  accuracy.  Powders  may  also  be  appHed  to  the 
oesophagus  with  good  results,  and  are  probably  the  best  form  of 
topical  remedy  for  that  region.  Laryngeal  insufflation  for  con- 
gestion and  the  minor  forms  of  disease  situated  below  the  epiglottis 
are  not  only  unnecessary  but  are  often  injurious  rather  than 
beneficial.    They  are,  moreover,  often  administered  quite  inap- 


FiG.  LXXXIII. — Simple  Caustic  Holder  for  Pharynx  and  Upper  Portion  of 
Larynx,  viz.,  an  Aluminium  Rod  charged  with  Fused  Nitrate  of  Silver 
(Half  Measurements). 

propriately,  as,  for  instance,  in  one  case  which  came  under  my 
notice,  to  give  relief  to  the  cough  of  an  aneurism  of  the  aorta 
pressing  on  the  left  recurrent  laryngeal  nerve. 

The  most  economical,  convenient,  and  for  general  purposes  safest 
caustic-holder  (Fig.  LXXXIII.)  is  a  piece  of  curved  aluminium 
rod — an  old  brush-handle  may  be  convenientl}^  used — which  is 
charged  by  simply  dipping  the  point  into  fused  nitrate  of  silver  ; 
a  little  of  the  silver  salt  can  be  kept  in  a  porcelain  crucible  and 


THERAPEUTICS  OF  THROAT  DISEASES, 


129 


melted  by  means  of  a  spirit-lamp  when  it  is  required  to  recharge 
the  aluminium  points.  For 
the  application  of  chromic 
acid  I  employ  copper  wires 
with  round  or  flat  ends,  on 

which  the  slightly  dehquesced  acid  can  readily  be 
fused.  For  laryngeal  use,  to  have  guarded  caustic- 
holders  constructed  on  the  principle  of  Lallemand's 
urethral  cauterizer,  are  necessary.  One  of  this 
description  is  shown  in  Fig.  LXXXIV.  It  is  a 
modification  devised  by  Dr.  Jarvis,  of  New  York, 
and  is  recommended  by  him  for  the  especial  pur- 
pose of  making  applications  of  fused  chromic  acid 
to  laryngeal  growths  not  easy  of  removal  by  snares. 
For  this  purpose  I  have  myself  usefully  employed 
it,  as  well  as  for  ordinary  cauterizations.  The 
instrument  consists  of  a  cannula  containing  a 
movable  metallic  rod,  at  the  end  of  which  is  placed 
the  caustic,  and  is  continued  in  the  form  of  a  spiral 
spring  at  the  curved  portion  of  the  tube.  The 
spring,  regulated  by  a  set  screw  on  the  principle  of 
the  tube  forceps,  serves  as  a  buffer  to  deaden  the 
force  of  the  probe's  impact  against  the  growth. 
The  handle  of  the  applicator  is  hollow  to  receive 
the  spring,  which  is  set  and  relieved  by  a  rack 
movement  under  the  control  of  the  operator. 

Up  to  this  point  the  forms  of  remedies  described 
have  been  those  which  are  directed  almost  entirely 
to  diseases  of  the  mucous  membrane  or  submucous 
tissue,  with  absence  of  serous  infiltration,  and 
prior  to  the  stage  of  new  formations.  It  will  be 
more  convenient  to  allude  to  or  describe  those 
instruments  which  are  required  for  various  recog- 
nised surgical  operations  on  the  throat,  in  the 
places  in  which  the  disease  to  be  so  treated  is 
considered  ;  but  it  may  not  be  inappropriate  to  our 
consideration  of  general  therapeutics  to  make  men  - 
tion here  of  some  instruments  generally  surgical, 
and  also  of  some  others  which  appear  to  me  to  be 
opposed  to  the  principles  I  have  promulgated  for 
guidance  in  our  treatment  of  throat  affections. 

Bleeding  and  Scarification  by  leeches  or  ex- 
ternal cupping  have  never  been  employed  by  me,  and  are  not 
advocated  ;  nor  do  I  think  that  punctures  with  the  lancet  of 


I30  DISEASES  OF  THE  THROAT  AND  NOSE. 

pharyngeal  or  faucial  swellings,  unless  there  is  distinct  evidence  of 
the  presence  of  pus,  are  attended  by  more  than  slight  and 
temporary  relief ;  but  in  the  larynx,  where  oedematous  swelling 
may  occur  to  such  an  extent  as  to  endanger  life,  scarification  by 
means  of  the  laryngeal  lancet  (Fig.  LXXXV.)  will  often  be  found 
necessary,  and  its  use  will  be  followed  by  noteworthy  benefit. 
The  unguarded  laryngeal  lancet  is  a  very  dangerous  instrument. 

With  regard  to  instruments  for  removing  grovi^ths  from  the 
larynx,  my  firm  conviction,  based  on  experience,  is  that  those  now 


Fig.  LXXXV.— Laryngeal  Lancet  (Half  Measurements). 


most  generally  in  use  are  far  more  dangerous  than  those  formerly 
employed.  At  first,  all  instruments  for  the  removal  of  growths 
were  on  the  principle  of  a  snare ;  gradually,  however,  we  got 
tube  forceps,  guillotines,  rigid  loops  with  sharp  edges,  fenestrated 
knives,  forceps,  some  of  them  strong  enough  to  break  a  vesical 
calculus,  scissors,  knives,  guarded  and  unguarded,  and  the  galvano- 
cautery. 


Fig.  LXXXVL— Gibb's  Laryngeal  Snare  (Half  MeasjURements). 


The  wire  loop  passed  through  two  eyes  at  a  travels  along  an  open  cannula  tube,  bridged 
at  ^  and  is  secured  at  c  to  the  movable  crosspiece,  traction  on  which  diminishes  the 
size  of  the  loop.  This  cross  bar  may  often  be  conveniently  changed  from  the 
horizontal  to  the  perpendicular  position. 

This  work  being  intended  mainly  for  the  general  practitioner,  and 
laryngeal  growths  being  happily  rare,  it  is  not  necessary  to  enter 
largely  into  the  subject.  It  may,  however,  be  stated  as  a  general 
principle,  with  respect  to  laryngeal  instruments  whether  for  growths 
or  otherwise,  that  it  is  impossible  for  them  to  be  too  dehcate,  and 
that  they  should  all  be  constructed  on  the  axiom  '  Primum  non 
nocere:    The  laryngeal  snare  of  Gibb  (Fig.  LXXXVL)  is  a  most 


THERAPEUTICS  OF  THROAT  DISEASES. 


valuable  instrument  for  many  small  pedunculated  growths,  and  the 
guarded  instruments  of  Stoerk  and  Jellenfy  are  also  constructed  in 
accordance  with  the  proposition  just  laid  down.  My  colleague,  Mr. 
Carmalt  Jones,  has  recently  devised  an  excellent  instrument  (Fig. 
LXXXVIL),  which  I  have  successfully  employed  in  several  opera- 
tions. Its  principal  feature  of  improvement  consists  in  the  instru- 
ment remaining  fixed  at  the  point  at  which  it  is  placed  while  the 
wire  noose  is  being  drawn  up.  Another  instrument  of  great  value, 
and  more  generally  employed  by  some  of  my  colleagues  than  by 


Fig.  LXXXVII. — Carmalt  Jones's  Laryngeal  and  Nasal  Snare. 

A  is  a  movable  cap,  with  two  holes  through  which  the  wire  of  the  snare  passes.  B,  the 
tube  guarding  the  wire,  the  ends  of  which  are  fixed  to  a  screw-catch,  C.  E  represents  a 
bar  continued  through  the  body  of  the  instrument ;  the  catch  C  is  fixed  on  to  this  bar, 
and  runs  in  a  slot  in  the  top.  F  is  a  nut  running  on  E  ;  it  regulates  the  size  of  the 
loop,  and  by  increasing  the  leverage  is  useful  when  the  part  to  be  divided  is  very  tough. 
G,  a  bar  similar  to  E,  but  ending  in  a  plate  for  pressure  of  the  thumb  of  operator.  H,  a 
pinion  ;  the  bars  E  and  G  are  racked  and  work  against  H.  Pressure  driving  in  G  causes 
H  to  revolve,  E  to  be  drawn  out,  and  consequently  tension  is  made  on  the  snare.  The 
cap  A  allows  of  the  snare  being  turned  round  in  the  axis  of  the  distal  part  of  the  tube 
to  any  angle,  and  by  pulling  off  the  cap  the  snare  is  reset  after  use — all  f.hat  is  necessary 
is  to  shape  it.    The  wire  used  is  steel  piano-wire. 

myself,  is  the  laryngeal  sponge  probang,  first  described  in  print 
by  Voltolini  (Fig.  LXXXVIII.),  though  the  method  had  been 
pursued  by  my  deceased  friend,  Llewelyn  Thomas,  some  years 
previous  to  the  publication  of  Voltolini's  paper.  One  case  is 
mentioned  in  my  first  edition  (1878).  Tube  forceps  and  rigid 
cutting-loops  are  sometimes  useful,  but  neither  are  absolutely 
safe  against  the  risk  of  doing  injury  to  healthy  tissues.  All  un- 
guarded forceps  are  dangerous,  and  can  hold  no  necessary  or 
justifiable  position  in  the  surgeon's  laryngeal  armament.  In  this 
opinion  I  have  been  supported  by  my  colleagues  at  the  Central 


A 


A 


132 


DISEASES  OF  THE  THROAT  AND  NOSE. 


London  Throat  and  Ear  Hospital  during  a  period  of  over 
seventeen  years,  and  no  laryngeal  growth  has  been  removed  in 
that  institution  by  an  unguarded  instrument. 


K 

Fig.  LXXXVIII. 

VoLTOLiNi's  Laryngeal  Sponge  Probang  (One-third  Measurements). 

To  show  that  these  words  of  caution  are  not  uncalled  for, 
facsimile  copies  have  been  made,  and  are  here  inserted,  of  some 


Fig.  LXXXIX. — Some  Varieties  of  Fauvel's  Laryngeal  Forceps  i«or  Removal 
OF  Growths  (Full  Measurements). 

of  the  instruments  used  by  Fauvel  and  figured  in  his  work  (Fig. 
LXXXIX.). 

Electro-Therapeutics.— The  application  of  electricity  to  the 


THERAPEUTICS  OF  THROAT  DISEASES. 


133 


pharynx,  larynx  and  oesophagus  may  be  required  for  the  following 
purposes,  which  practically  embrace  the  range  of  its  application 
in  the  diseases  under  our  consideration  :  (i)  Illumination  ;  (2) 
cauterization ;  (3)  electrolysis ;  (4)  excitation  of  nerves  and 
muscles.  The  methods  will  be  the  more  readily  understood  after 
a  brief  review  of  a  few  fundamental  principles. 

Two  kinds  of  electricity  are  recognised :  {a)  Static,  frictional, 
or  Franklinic ;  and  (6)  dynamic.  The  former  is  electricity  in  a 
state  of  rest ;  the  latter  is  considered  to  be  electricity  in  a  state  o 
motion,  and  is  the  one  generally  employed,  the  static  variety 
being  restricted  for  application  to  some  forms  of  hysteria.  In 
using  the  dynamic  form,  it  will  be  as  well,  fir^t,  to  understand  the 
meaning  of  the  terms  *  electro-motive  force  '  (E.M.F.),  '  current ' 
(C),  and  *  resistance '  (R.) ;  secondly,  to  understand  the  means 
whereby  this  force,  current,  and  resistance  are  produced,  governed 
and  adapted  to  the  various  conditions  for  which  they  may  be 
required.  The  terms  can  be  well  illustrated  by  comparison  with 
the  vascular  system,  the  electro-motive  force  being  represented 
by  the  pumping  force  of  the  heart,  the  current  by  the  velocity 
of  the  blood-flow  through  the  vessels,  whilst  the  resistance  finds 
its  equivalent  in  the  peripheral  friction  of  the  blood  against  the 
lining  of  the  vessels.  The  electro-motor  force  is  measured  by  Volts, 
the  current  hy  Amperes,  and  the  resistance  by  Ohms.  The  practical 
applications  of  these  several  terms  can  be  the  more  readily 
demonstrated  by  objective  illustrations,  and  for  this  purpose  we 
may  select  that  of  illumination.  In  this  case,  resistance  being 
small,  we  shall  require  a  low  force,  or  voltage  (E.M.F.) — say,  five 
volts — but  a  strong  current  of,  at  least,  two  or  three  amperes.  As 
a  second  illustration  we  may  take  that  of  a  cautery  point,  in 
which  a  still  lower  E.M.F.  is  required,  but  a  very  much  stronger 
ctirrent — say,  one  of  thirty  amperes.  Lastly,  to  take  one  more 
illustration,  that  of  excitation  of  a  nerve  or  muscle,  in  which  the 
resistance  is  high,  we  should  require  a  high  E.M.F.,  equal  to 
perhaps  forty  volts,  but  only  a  weak  current  of,  say,  ten  milli- 
amperes,  for  if  the  current  were  too  strong  it  would  act  as  a 
Cautery.  The  question  of  electricity  in  relation  to  illumination 
has  already  been  considered  (page  39),  and  we  will  at  once 
proceed  to  speak  of  its  application. 

Broadly  speaking,  the  most  serviceable  arrangements  will  be 
as  follows  :  For  cautery  as  for  illumination  we  employ  a  bichro- 
mate battery  or  an  accumulator,  from  which  a  powerful  current 
can  be  obtained ;  whilst  for  nerve  or  muscular  excitation  and  for 
electrolysis  we  should  use  a  Leclanche  battery,  in  which  the 
cm  rent  is  low,  but  which  affords  a  high  E.M.F. 


134 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Whatever  may  be  the  form  of  battery  employed,  a  rheostat  is 
necessary  to  regulate  the  intensity.  It  remains  only  to  say  that 
electric  currents  may  be  either  continuous  or  interrupted,  the 
latter  being  generally  known  as  the  Faradic,  and  it  is  this  form 
that  is  mainly  employed  for  pareses,  due  to  peripheral  conditions, 
the  continuous  being  reserved  for  those  cases  in  which  the  lesions 
are  central.  The  Faradic  current  is  especially  valuable  in  many 
of  the  minor  disorders  of  the  throat  and  larynx.  It  has  also  been 
recommended  to  be  applied  to  the  Eustachian  tube  through  either 
the  posterior  or  anterior  nares,  and  again  to  the  membrana  tym- 
pani.  The  best  instrument  for  these  purposes  is  that  of  Mackenzie 
(Fig.  XC),  slightly  varied  according  to  the  part  to  be  treated. 
This  apparatus  consists  of  a  necklet  {B)  in  connection  by  a  chain 
{ch)  with  one  pole  of  the  battery,  the  other  being  conducted  to  an 
electrode  {A),  so  arranged  that  the  current  (c)  does  not  pass  from 
the  point  (/)  until  a  small  spring  {d)  in  the  handle  is  pressed  upon 
by  the  finger.  The  advantage  of  this  is  that  no  current  is  passed 
into  the  larynx  until  the  instrument  is  in  the  required  position  ;  e.g., 
in  contact  with  the  vocal  cords.  The  inventor  of  this  instrument 
has  also  described  double  electrodes,  by  means  of  which  it  is 
supposed  that  particular  muscles  of  the  larynx  may  be  subjected 
to  the  action  of  the  electric  current.  Such  ideas  can  only  be 
regarded  as  flights  of  too  vivid  imaginations,  or,  at  least,  as 


Fig.  XC— Laryngeal  Electrode  (One-third  Measurements). 


pertaining  to  details  of  specialism  too  refined  for  present  con- 
sideration. It  is  to  be  noted  that  in  many  cases  application  of 
the  current  percutaneously  is  sufficient  without  introduction  of 
the  electrode  into  the  throat ;  nor  is  it  by  any  means  necessary  in 
all  circumstances  even  to  attempt  to  enter  the  larynx — for  a  brisk 
current  to  lips,  tongue,  or  fauces,  if  accompanied  by  firm  moral 
influence  and  cncoiira^:;cment  of  the  patient,  will  frequently  restore  a 
voice  lost  by  simple  functional  causes.  The  constant  current  is 
limited  in  its  application  to  diseases  of  the  throat  as  a  means  for 
diagnosis,  e.g.,  atrophy  of  muscle  ;  and  for  electrolysis,  as  a  means 


THERAPFMTICS  OF  THRO  A  T  DISEASES.  135 

of  disintegration  of  a  new  growth,  in  addition  to  its  utility  for 
the  purposes  of  cauterization,  as  already  explained. 

Galvano-Cautery.— This  application  of  electricity  has  proved 


llllllllllllllllllllllllllllllllllllllllil 

IHIIIIIIIIIIIIIIIIIIIIIIlllllllllllllllllllllllll 

III 

iiiiiiiiliiii 

Iji  1 

'  111  1 

Fig.  XCI. — Author's  Galvano-Caustic  Battery,  with  Foot-piece  (Mayer). 


The  side  of  the  Lattery  Is  taken  out  to  show  the  arrangement  for  bringing  the  plates  in 
contact  on  lifting  the  lid. 


highly  useful  in  many  cases  of  throat  disease,  especially  those  of 
a  specific  character,  as  well  as  in  some  affections  of  the  nose  and 
ear. 


136 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  apparatus  (Fig.  XCI.)  which  I  am  in  the  habit  of  using,  and 
which  was  made  for  me  more  than  sixteen  years  ago  by  Messrs. 
Mayer  and  Meltzer,  consists  of  a  battery  of  two  cells  charged 
with  bichromate  of  potash  solution,  each  cell  having  four  zinc  and 
carbon  plates.  This  battery  is  very  convenient  in  size,  measuring 
only  12  inches  in  height  by  g  inches  square.  Contact  is  made  by 
the  foot  of  the  operator  pressing  on  a  key,  both  hands  being  thus 
left  free,  while  at  the  same  time  the  current  is  entirely  under  the 
control  of  the  operator  himself.  This  battery  is  put  into  action 
by  pushing  back  the  lid  of  the  case,  and  is  out  of  action  when  the 
lid  stands  vertical  or  the  case  is  closed. 

Until  quite  recently  I  employed  alternatively  a  smaller  but  more 
powerful  battery,  made  for  me  by  Coxeter  ;  but  this  is  now  super- 
seded by  the  excellent  battery  supplied  by  the  Electric  Power 
Storage  Company  (Fig.  XCIV.)  as  adapted  by  the  same  maker. 
It  can  be  had  with  from  two  to  any  number  of  cells,  the  price, 
which  is  moderate,  being  at  the  rate  of  about  thirty  shillings  a 
cell.  For  private  requirements  two  to  four  cells  are  ample,  the 
current  lasting  without  re-charging  for  an  average  of  three  months 
with  daily  use.  They  are  absolutely  reliable,  but  cannot  be  em- 
ployed without  the  regulating  rheostat  which  Coxeter  has  fixed. 

In  all  my  batteries  the  insulated  conducting  cords  are  for  con- 
venience twisted  together,  except  at  the  ends  where  they  branch 
off  to  be  attached  at  the  separate  poles  of  the  battery  and  to  the 
cautery  handle  ;  they  are  made  light  and  flexible,  a  great  de- 
sideratum to  the  operator.  For  those  who  have  electricity  *  laid 
on '  in  their  houses,  Arnold  Woakes  has  suggested  a  converter  by 
which  the  interrupted  current  or  one  for  cautery  are  ready  to 
hand.    This  idea  has  been  well  carried  out  by  Schall. 

Papers,  with  cases  treated,  were  read  by  me  on  this  subject 
at  the  Manchester  meeting  of  the  British  Medical  Association 
(1877),  and  again  at  the  International  Medical  Congress  in  London 
(1881)  ;  the  following  are  the  conclusions  at  which  I  have  arrived : 

I.  That  the  galvano-cautery  is  most  useful,  being  more  rapid 
and  permanent  and  less  painful  (painless  under  cocaine)  than 
mineral  forms  of  caustic,  in  tertiary  specific  ulcerations  of  the 
fauces  and  soft  palate,  especially  in  cases  of  perforating  ulcer,  and 
w^hen  the  disease  is  congenital  or  hereditary,  or  where  there  is  a 
combined  scrofulous  diathesis;  and  also  for  destruction  of  varicose 
veins  of  the  pharynx  in  chronic  pharyngitis,  and  at  tile  base  of  the 
tongue.  It  is  for  this  and  all  other  purposes  in  which  the  cautery 
is  indicated  far  more  convenient  than  any  form  of  actual  cautery, 
since  it  can  be  introduced  along  delicate  cavities  cold,  and  after 


138 


DISEASES  OF  THE  THROAT  AND  NOSE, 


cauterization  be  withdrawn  cool ;  moreover,  its  action  is  limited 
to  the  point  touched. 

2,  For  removal  of  enlarged  tonsils,  the  method  is  unnecessarily 
painful  and  tedious,  and  generally  inefficient ;  but  it  surpasses 
any  other  for  destruction  of  diseased  lacunae  in  unenlarged  or  in 
atrophied  tonsils.  It  may  also  be  advantageously  employed  for 
removal  of  the  relaxed  tissue  of  an  elongated  uvula. 


JIG.  XCIV.— E.  P.  S.  Cautery  Accumulator  with  Rheostat. 

A,  for  graduating  the  strength  of  current. 

B,  new  cautery  handle  with  rack  movement  instead  of  screw,  etc, 
for  hot  or  cold  snare,  etc. 

3.  That  in  diseases  of  the  larynx,  except  where  occurring  m 
the  epiglottis,  the  cautery  is  only  exceptionally  admissible,  since 
there  is  great  danger  of  doing  serious  injury  to  healthy  tissues. 

4.  That  it  is  valuable  in  many  cases  of  hypertrophy  of  tissue  in 
the  vault  of  the  pharynx,  though  when  so  employed  precautions  are 
necessary  to  prevent  extension  of  inflammation  to  the  middle  ear. 


THERAPEUTICS  OF  THROAT  DISEASES, 


139 


5.  That  it  is  almost  invaluable  as  an  escharotic  and  alterant  in 
those  cases  of  nasal  and  naso-pharyngeal  disease  in  which  the 
secretion  is  altered,  whether  the  change  be  that  of  excessive  flow 
with  limpidit}^  or  arrest  and  inspissation,  the  two  representing  not 
infrequently  but  different  stages  of  one  pathological  condition. 

6.  That  nasal  polypi,  being  first  secured  by  suitable  self-holding 
forceps  (varieties  are  shown  in  Fig.  XCV.),  can  be  most  com- 
pletely removed  by  the  cautery  loop  (Fig.  XCIIL,  i  and  4),  with 
the  minimum  of  pain  and  haemorrhage,  as  well  as  without  risk  of 
injuring  surrou^nding  parts.    Subsequent  to  this  opinion  given  at 


1  2 

Fig.  XCV.— Instruments  for  Securing  a  Nasal  Polypus  at  its  Base  prior 
TO  passing  the  Wire  Loop  around  it  (Half  Measurements). 

Manchester — and  as  expressed  in  my  later  paper  at  the  Congress 
— I  now  preferably  remove  the  polypi  with  the  ordinary  cold  wire 
snare  or  forceps  (Figs.  LXXXVIL,  XCVL,  XCVIL,  XCVIII.,  or 
XCIX.),  and  reserve  the  cautery  for  later  applications  with  the 
intention  of  destroying  the  surface  of  the  bases  of  origin. 

7.  That  scrofulous  ulcerations,  diseased  bone,  and  submucous 
thickenings  or  outgrowths  in  the  same  region  can  be  treated 
with  equal  success,  and  better,  by  the  cautery  loop  than  by  the 
cold  snare  or  forceps. 

8.  That  after  removal  of  aural  polypi  in  the  ordinary  wa}^,  the 


I40  DISEASES  OF  THE  THROAT  AND  NOSE. 

cautery  may  be  applied  with  a  line-pointed  instrument  (Fig.  XCIIL, 
No.  3)  with  advantage  to  base,  with  a  view  of  preventing 
recurrence. 


xcvi. 


Figs.  XCVI.,  XCVII.,  XCVIIL,  and  XCIX. 


Fig.  XCVI.  Snare  for  nasal  polypus. 

Fig.  XCVII.  Hamilton's  ditto,  acting  either  as  a  slip  noose,  or  by  a  screw  movement 
as  an  ecraseiir. 

Figs.  XCVIII.  and  XCIX.    Forms  of  forceps  for  nasal  polypus,  each  with  catches  to 
secure  the  grip  when  the  instrument  is  closed.    The  latter  is  on  the  model  of  an  inven- 
•   tion  of  Mr.  Lund,  each  blade  consisting  of  a  double  culting-ring. 

g.  That  the  cautery  (with  the  same  cautery-point")  may  be  useful, 
under  certain  precautions,  in  those  cases  in  which  it  is  desired  to 
make  a  permanent  perforation  in  the  tympanic  membrane. 


THERAPEUTICS  OF  THRO  A  T  DISEASES. 


141 


10.  That  the  risk  of  haemorrhage  from  galvano-cautery  appHca- 
tions  can  be  averted  by  not  using  the  cautery-point  at  too  great  a 
heat,  the  same  being  regulated  by  means  of  a  rheostat.  A  black- 
heat  often  answers  for  all  that  is  required  ;  a  dull  red-heat  is 
seldom  needed,  and  by  me  never  exceeded ; 
a  bright  red-heat  is  quite  unnecessary,  and 
anything  like  white-heat  is  to  be  absolutely 
avoided  as  dangerous. 

II.  The  after-pain  of  galvano-cautery  is, 
in  my  experience,  much  less  than  that  follow- 
ing use  of  a  thermal  cautery,  acid  nitrate  of 
11  mercury,  or  caustic  pastes  of  soda  or  potash, 
in  which  there  is  diffusion  of  the  destructive 
agent  beyond  the  part  treated.  In  some 
regions  —  e.g.,  the  nose — the  after-pain  is 
often  nil. 

In  operations  on  the  nose  and  ear  it  is 
necessary,  or  at  least  desirable,  to  have  the 
passage  guarded  from  the  risk  of  being 
scorched  by  the  heat  of  the  wire.  In  aural 
cases  a  small  ivory  speculum  answers  the 
purpose ;  and  for  the  nose,  acting  on  an 
idea  suggested  by  Mr.  Bryant's  female 
urethral  dilator,  I  have  had  made  by  Mr. 
Krohne  an  ivory  cautery  protector  w^hich 
well  answers  the  purpose  where  the  opera- 
tion is  near  the  orifice. 

But  this  and  all  other  forms  of  protector 
are  now  superseded  by  my  nasal  dilator, 
already  described  (p.  78),  the  blades  of  w^hich 
are  made  of  ivory.  Notwithstanding  pre- 
cautions as  to  modified  heat  of  the  cautere, 
non-conducting  specula,  etc.,  the  accident  of 
an  inflammatory  otitis  may  occur.  After 
operations  in  regions  likely  to  lead  to  such  a 
contingency,  I  spray  the  nostrils  with  a 
warm  alkaline  solution  b}-  means  of  the 
'  Lefferts,'  apply  oil  and  cocaine  (5  per  cent.) 
on  wool  to  the  cauterized  surface,  and  some 
atropine  drops  (20  per  cent.)  to  the  drumhead  by  the  external 
meatus. 

I  agree  with  Shech  that  Massage  of  the  throat  gives  but  doubtful 
promise.  Nevertheless,  some  advance  has  recently  been  made  in 
this  procedure,  both  in  the  throat  and  the  nostrils.    My  own 


142  DISEASES  OF  THE  THROAT  AND  NOSE. 

experience,  however,  is  not  sufficient  to  speak  with  authority  on 
the  subject. 

The  last  instrument  to  be  mentioned  in  this  chapter  is  that  for 
the  detecting,  catching  and  withdrawal  of  foreign  bodies  from  the 
oesophagus  or  pharynx.  The  one  I  prefer  is  that  known  as  the 
*  Ramoneur,'  with  two  modifications — {a)  that  the  end  (Fig.  CI.,  i) 
is  of  ivory  or  metal,  instead  of  sponge,  for  the  striking  and  conse- 
quently better  detection  of  coins  or  other  solid  foreign  body ;  and 
(6)  the  addition  of  two  small  pins.  The  first  (2),  working  in  a 
socket,  prevents  the  expansion  of  the  net  during  introduction  ; 
the  second  (3)  enables  the  surgeon  to  keep  the  hair  net  spread 
when  once  drawn  up.  This  arrangement  allows  him  to  have  much 
greater  delicacy  of  touch  than  is  possible  if  he  is  obliged  (as  is  the 
case  in  the  instruments  usually  made)  to  be  continually  keeping 
tension  on  the  piston.  For  pocket  use  I  have  had  this  instrument 
hinged  at  the  centre.  I  am  also  in  the  habit  of  carrying  oesophageal 
bougies  of  half-length,  which  can  be  screwed  together  for  use.  A 
long  pair  of  forceps  is  the  best  instrument  for  withdrawal  of  foreign 
bodies  from  the  larynx.  Voltolini's  sponge  probang  (Fig. 
LXXXVIII.)  is  sometimes  serviceable.  If  in  the  trachea,  the 
windpipe  had  better  be  opened  at  once. 

Tracheotomy. — A  question  will  often  arise  as  to  the  relative 
merits  of  early  and  of  late  tracheotomy  in  chronic  disease  of  the 
upper  air  passages,  and,  for  that  matter,  the  question  whether 
the  operation  should  or  should  not  be  performed  at  all ;  and  it  is 
one  which  has  hitherto  rather  escaped  the  attention  of  writers, 
though  in  practice  it  is  naturally,  or  at  least  should  be,  considered 
in  every  case  that  comes  under  the  surgeon's  notice.  Notwith- 
standing that  the  laryngoscope  has  now  been  in  use  for  thirty 
years,  the  operation  is  still  for  the  most  part  performed  on  indica- 
tions— more  or  less  accurate — of  urgent  dyspnoea,  with,  to  say  the 
least  of  it,  insufficient  attention  to  the  physical  nature  of  the 
obstruction,  or  to  the  possibility  of  relieving  it  by  other  than  sur- 
gical means.  The  subject  is  treated  in  this  edition  with  somewhat 
more  detail,  my  own  attention  having  been  prominently  directed 
to  it,  as  the  result  of  an  invitation  to  open  a  discussion  thereon  at 
an  early  meeting  of  the  British  Laryngological  Association.  My 
paper  was  published  in  the  Journal  for  Laryngology,  for  April, 
1889.  As  a  general  and  preliminary  basis  of  our  consideration,  I 
would  venture  to  announce  certain  postulates  : 

[a)  Tracheotomy  is  indicated  in  chronic  laryngeal  disease  (i)  on 
account  of  urgent  dyspnoea  caused  by  an  exacerbation  of  inflam.- 
mation  in  the  course  of  a  chronic  malady ;  and  (2)  in  certain 
diseases  in  which  our  prognosis  points  to  a  progressive,  though 


THERAPEUTICS  OF  THROAT  DISEASES, 


43 


possibly  gradual,  increase  of  respiratory  difficulty.  In  the  latter 
case  the  operation,  if  performed  early — that  is  to  say,  as  soon  as 
continued  dyspnoea  becomes  a  prominent  symptom — is  more 
likely  to  be  both  immediately  and  remotely  successful,  than  if 
delayed  until  resulting  pulmonary  changes  have  become  pro- 
nounced. 

(6)  The  degree  of  vital  danger  which  exists  in  a  case  of  laryn- 
geal and  tracheal  obstruction  depends  mainly  on  the  situation  of 
the  lesion. 

(c)  Supra- glottic  obstruction  rarely  causes  vital  risk.  For 
example,  inflammation,  acute  or  chronic,  unaccompanied,  be  it 
premised,  by  true  oedema,  and  leading  to  thickening,  ulceration, 
and  cicatrisation  of  the  epiglottis,  ary-epiglottic  folds,  or  of  the 
ventricular  bands,  is  not  often  accompanied  by  urgent  dyspnoea, 
and  this  is  indifferently  true,  whether  the  case  be  one  of  phthisis, 
lupus,  or  syphilis.  I  have  made  an  exception  with  regard  to  true 
oedema,  not  such  as  exists  in  phthisis,  which  is  in  no  sense  of  that 
nature,  because  I  am  of  opinion,  with  Sestier  and  Morell  Mac- 
kenzie, that  not  only  is  oedema  of  the  larynx  much  more 
rare  than  is  generally  supposed  in  Bright's  disease — Mackenzie 
did  not  find  it  once  in  200  cases — or  in  general  anasarca,  but  also 
*  that  the  intervention  of  a  phlegmasia  of  the  pharynx  and  larynx, 
or  neighbouring  tissues,  is  nearly  always  necessary.'  I  would  go 
further,  and  express  my  belief  that  neither  in  the  case  of  such  an 
acute  oedema,  accompanied  as  it  is  by  a  general  phlegmasia, 
usually  the  result  of  a  septicaemia,  nor  in  that  of  one  occurring  in 
the  course  of  a  chronic  syphilitic  laryngitis,  and  causing  difficulty 
of  breathing,  is  the  oedema  often  limited  to  supra-glottic  regions, 
but  that  that  most  dangerous  of  all  situations,  the  portion  imme- 
diately below  the  glottis,  is  almost  invariably  involved,  and  that 
this  is  proved  subjectively,  even  where  not  visible,  by  the  character 
of  the  dyspnoea. 

An  exception  in  some  sense  has  also  to  be  made  to  this  proposi- 
tion in  regard  to  cancer,  in  which  the  disease,  although  it  be 
apparently  situated  at  a  spot  not  interfering  with  the  glottic 
patency,  may,  by  extension  into  the  deeper  tissues,  produce  an 
obstruction  which  is  to  all  clinical  intents  and  purposes  of  the 
nature  of  a  neurosis — that  is  to  say,  it  is  due  to  a  paralysis  of 
intrinsic  respiratory  muscles. 

(d)  Obstruction  of  the  lumen  of  the  glottis  itself — by  which  I 
mean  of  that  space  bounded  by  the  vocal  cords — may  be  consider- 
able without  producing  vital  dyspnoea.  Examples  of  the  truth  of 
this  statement  are  frequently  afforded  in  the  case  of  benign  neo- 


144  DISEASES  OF  THE  THROAT  AND  NOSE. 


plasms,  when  attached  by  broad  bases  to  the  superior  surface  or 
free  edge  of  the  vocal  cords.  The  circumstance  of  this  absence  of 
respiratory  difficulty  is  indeed  of  high  diagnostic  import  in  regard 
to  their  benign  character. 

A  like,  though  not  so  complete,  an  immunity  is  also  observed 
in  cases  of  congenital  or  cicatricial  webs  of  the  vocal  cords  where 
there  is  no  implication  of  other  contiguous  structure. 

(e)  Sub-glottic  obstruction,  whatever  the  cause,  is  always 
attended  with  the  gravest  danger  to  life,  and  it  can  be  further 
postulated  that  the  lower  the  situation  of  the  obstruction  in  the 
windpipe,  the  greater  is  the  risk ;  and  also  the  less  is  the  chance 
of  relief  being  afforded  by  an  artificial  opening. 

(/)  It  is  not  unimportant  to  premise— though  less  so  than  it 
was  twenty  years  ago — that  no  tracheotomy  ought  to  be  advised, 
much  less  performed,  on  account  of  chronic — it  might  indeed  be 
said  any — laryngeal  disease  without  a  thorough  preliminary  inves- 
tigation with  the  laryngoscope,  and  further,  that  the  same  means 
of  information  should  be  practised  before  a  tracheotomy  tube  is 
removed. 

One  of  the  first  cases  of  tracheotomy  in  ray  independent  hospital  experience  illustrated 
the  necessity  for  enforcing  this  precaution,  as  well  as  the  unwisdom  of  neglecting  it.  It 
occurred  to  me  in  1874,  in  the  person  of  a  gentleman's  servant,  who  had  been  tracheoto- 
mised  by  the  house  surgeon  of  a  hospital  boasting  a  special  throat  department,  which  was 
presided  over  by  both  a  physician  and  surgeon.  Not  only  v;as  no  laryngoscopic  examina- 
tion made  prior  to  the  opening  of  the  windpipe — that  might  well  have  occurred — but  the 
tube  was  removed  after  eleven  weeks,  and  the  patient  discharged  without  such  a  step  having 
been  taken.  The  man  came  under  my  hands  less  than  six  months  later,  and  was  found 
to  be  the  subject  of  serious  stenosis,  due  to  syphilis.  It  was  urgently  necessary  to  repeat 
the  operation,  and  though  I  had  the  opportunity  of  seeing  the  patient  for  many  yeai.' 
afterwards,  I  was  never  able  to  advise  withdrawal  of  the  tube. 

As  further  illustrations,  one  has  only  to  look  through  the  morbid 
specimens  in  our  various  museums  to  see  how  many  cases  there 
were  in  pre-laryngoscopic  days  in  which  tracheotomy  was 
unnecessarily  performed,  and  to  recall  as  one — doubtless  of  many 
similar — the  case  under  the  care  of  Liston,  quoted  by  Solis-Cohen, 
in  which  a  stenosis,  having  been  successfully  dilated  through  the 
tracheotomy  wound  from  below,  the  tube  was  withdrawn,  but  had 
to  be  re-inserted  on  the  following  day. 

It  is  fair,  therefore,  to  make  this  postulate,  that  while  the  more 
expert  the  laryngologist,  both  in  diagnosis  and  therapeusis,  the 
less  frequent  will  be  tracheotomy  in  his  practice ;  so  also  the  less 
liable  will  the  patient  be  to  suffer  from  either  a  too  early  with- 
drawal or  a  too  prolonged  retention  of  the  tube. 

I  have  no  intention  of  entering  into  any  detailed  description  of 
the  operation,  but  would  simply  say  that,_except  for  cases  of 


THERAPEUTICS  OF  THROAT  DISEASES. 


M5 


urgency,  and  in  which  the  tube  will  not  be  required  for  more  than 
a  few  days,  I  never  perform  or  advise  laryngotomy — that  is,  intro- 
duction of  the  tube  through  the  crico-thyroid  space.  Such  an 
operation  is  virtually  never  indicated  in  chronic  disease  and  seldom 
in  acute  maladies.  Nor  do  I,  if  possible,  ever  make  an  opening 
that  does  not  leave  the  first  ring  of  the  trachea  undivided — for 
division  of,  or  pressure  of  the  tube  on  the  cricoid  cartilage,  is  very 
likely  indeed  to  be  followed  by  caries  of  that  structure  and  other 
complications.  Such  a  limit  in  my  practice  represents  the  high 
operation,  while  by  the  low  operation  I  intend  to  convey  one  in 
which  the  trachea  is  opened  below  the  inferior  boundary  of  the 
third  ring. 

With  regard  to  tubes,  without  doubt  the  rectangular  tube  of 
Durham  carries  the  palm  for  all  cases  in  which  the  instrument  has 
to  be  worn  for  any  length  of  time,  and  is  also  the  best  in  the  first 
instance  where  one  has  plenty  of  assistants.  But,  though  the  old 
bi-valve  tube  of  Fuller  has  been  very  uncompromisingly  con- 
demned of  recent  years,  the  ease  with  which  it  can  be  introduced 
where  hands  to  hold  retractors  and  the  assistance  of  dilators  are 
not  available,  renders  this  instrument  a  very  serviceable  one  to 
the  country  operator  for  first  use  in  cases  of  emergency.  What- 
ever tube  is  employed,  I  endeavour  to  leave  it  unchanged  for 
forty-eight  hours,  and  then  insert  the  one  which  is  to  be  retained 
for  the  whole  length  of  time  of  its  use. 

Further  remarks  regarding  other  operative  procedures  on  the 
larynx  may  be  deferred  till  consideration  of  the  treatment  of 
the  various  diseases  in  which  they  are  required. 

Anaesthetics. — Of  local  methods  cocaine  stands  first,  and  to  the 
use  of  this  drug  I  have  already  alluded  more  than  once.  For 
operations  on  the  phj^rynx  and  larynx  I  employ  a  spray,  and  find 
that  anaesthesia  is  generally  sufficiently  pronounced  to  commence 
operating  in  from  five  to  seven  minutes.  Sometimes,  as  in  the 
case  of  lingual  varix,  or  in  hypertrophy  of  the  lingual  tonsil— the 
solution  may  require  to  be  'rubbed  in,'  ihis  may  be  done  by 
means  of  a  brush.  It  should  not  be  forgotten,  especially  in  opera- 
tions on  the  young,  that  the  amount  of  cocaine  administered  by  a 
spray  may  be  enough  to  produce  serious  toxasmic  effects,  and 
indeed,  at  least  one  fatal  case  due  to  this  cause  has,  to  my  know- 
ledge occurred.  For  the  relief  of  after-pain  of  operations  such  as 
tonsillotomy  and  uvulotomy,  I  employ  a  soft  lozenge  containing 
a  tenth  of  a  grain  of  cocaine  in  each. 

For  intra-nasal  procedures  I  apply  a  solution  on  pledgets  of 
cotton  wool,  which  should  be  retained  from  ten  to  fifteen  minutes. 

10 


46 


DISEASES  OF  THE  THROAT  AND  NOSE. 


It  is  often  necessary  to  use  a  solution  of  a  greater  strength 
than  ten  per  cent.  ;  but  occasionally  for  the  more  painful  intra- 
nasal operations,  such  as  those  involving  the  use  of  the  trephine 
savs^  or  cautery,  it  may  be  w^ell  to  add  a  little  of  the  solid  salt 
on  the  moistened  w^ool  which  is  to  be  retained  v^ithin  the  nostrils 
for  about  three  minutes  before  commencing  to  operate. 

For  some  external  operations,  such  as  removal  of  glands  in 
the  neighbourhood  of  the  neck,  hypodermic  injection  of  cocaine  is 
very  efficient.  Even  for  tracheotom.y,  five  to  ten  minims  of  a  ten 
per  cent,  solution  injected  on  each  side  of  the  immediate  region  at 
which  the  trachea  is  to  be  opened,  will  produce  nearly  complete 
insensibility  of  the  skin.  Ten  to  twelve  minutes  should  be  allowed 
to  elapse  before  commencing  an  operation,  and  in  the  majority  of 
instances  pain  will  not  be  felt  even  from  the  first  incision  through 
the  skin.  Local  anaesthesia  can  thus  be  maintained  sufficiently 
long  to  allow  of  a  careful  and  leisurely  performance  of  the  opera- 
tion. Beyond  the  advantages  of  cocaine  as  a  local  anaesthetic,  this 
remedy  so  apphed  has  the  effect  of  depriving  the  part  of  blood, 
and  thereby  diminishing  haemorrhage  during  the  operation,  whereas 
with  chloroform  and  ether  the  contrary  effect  is  often  produced.  It 
also  quiets  the  breathing  and  steadies  the  larynx  in  cases  in  which 
respiration  is  seriously  hurried. 

It  is  necessary  to  repeat  the  caution  which  I  have  already  pub- 
lished {British  Medical  Journal,  April  27th  and  June  ist,  i88g) 
against  allowing  patients  to  use  cocaine  indiscriminately  for  relief 
of  quite  slight  symptoms  of  chronic  conditions.  This  is  a  danger- 
ous procedure,  for  the  twofold  reason  (i)  that  the  drug  loses  even 
its  analijesic  action  after  long  use,  as  is  exemplified  in  the 
diminished  relief  it  affords,  after  a  time,  to  dysphagia  occasioned 
by  tuberculous  or  other  ulceration — the  most  justifiable  indication 
for  its  continuous  employment.  (2)  While  cocaine,  in  the  first 
instance,  promotes  salivary  and  mucous  secretion,  it  is  found  that 
patients  who  long  indulge  in  applications  of  this  drug  suffer  later 
from  abnormal  dryness  of  the  throat.  Further,  its  good  effect  in 
temporarily  relieving  capillary  engorgements  of  the  turbinated 
bodies,  etc.,  results,  if  its  use  is  unduly  prolonged,  in  either  an 
anaemia  with  atrophy,  or  a  no  less  inconvenient  increase  in  the 
intensity  and  chronicity  of  the  hyperaemia.  I  have  seen  two 
cases  in  which  I  believe  anosmia  to  have  been  induced,  or  at  least 
aggravated  from  this  habit.  Tetanic  spasms  have  also  been 
noticed  as  an  effect  of  long  use  of  this  drug.  Needless  to  add  that 
the  amount  of  cocaine  absorbed  into  the  system  has  an  injurious 
general  effect  on  the  health  in  the  shape  of  a  debilitated  vaso- 


THERAPEUTICS  OF  THROAT  DISEASES. 


147 


motor  system  ;  this  is  accompanied  byaprosexia,  loss  of  memory, 
Avant  of  decision,  hypochondriasis  and  depression  of  energy,  spirits 
and  intellectual  powers. 

Where  deep  general  narcosis  is  required  and  the  operation  is 
short,  nitrous  oxide  will  be  sufficient.  In  other  cases  I  am  in  the 
habit  of  commencing  with  nitrous  oxide  and  continuing  with 
•ether.  A  disadvantage  of  the  last-named  drug  is  its  disposition  to 
increase  salivary  secretion  and  vascular  turgescence,  in  these 
respects  being  inferior  to  chloroform,  which,  however,  has  certain 
disadvantages  of  vital  risk  of  much  more  importance. 

Dietetics  and  Hygiene.  —  A  chapter  on  the  therapeutics 
•of  throat  diseases  would  be  incomplete  without  some  remarks 
respecting  the  dietetic  and  hygienic  measures  necessary  for  the 
treatment  and  prophylaxis  of  those  affections.  With  respect  to 
such  directions,  it  must  be  remembered  that  in  throat  affections 
three  distinct  functions  are  interfered  with,  viz.,  deglutition, 
respiration,  and  vocalization.  The  principal  difficulty  in  their 
treatment  lies  in  the  impossibility  of  giving  them  perfect  rest,  two 
of  them  at  least  being  vital  functions.  The  great  object,  however, 
must  be  to  give  each  as  little  work  to  do  as  possible. 

Deglutitory. — In  all  cases  of  relaxation  and  congestion  of 
pharyngeal  mucous  membrane,  every  form  of  pepper,  spices,  and 
hot  condiments  should  be  avoided. 

Ice  will  often  be  found  most  grateful  to  the  throat,  but,  in  order 
to  avoid  injury  to  the  digestion,  it  should  always  be  taken  mid- 
way between  meals,  and  not  just  before  one. 

Special  dietary  rules  are  called  for  in  those  cases  in  which  the 
constitutional  foundation  of  the  local  ailment  is  an  essential 
feature  for  treatment.  Recognising  the  lithic  acid  diathesis  as  a 
predisponent  of  a  majority  of  throat  diseases  in  the  pharyngeal — 
or  more  correctly  faucial — region,  I  am  particular  to  caution 
against  those  articles  of  food,  both  solid  and  fluid,  likely  to  favour 
fermentative  dyspepsia..  Further  details  on  this  head  are  not 
necessary  in  this  place. 

Soft  food  is  often  absolutely  necessary  in  throat  affections,  and 
it  is  also  frequently  essential  that  such  food  should  be  given  in 
the  most  concentrated  form,  in  order  to  give  the  deglutitory  func- 
tion as  little  work  as  possible.  Extracts  made  from  fresh  meat 
are,  in  my  judgment,  preferable  to  the  concentrated  preparations, 
such  as  Liebig's.  A  very  excellent  form  for  the  administration  of 
nourishment,  and  one  which  can  be  employed  even  in  very  con- 
siderable obstruction  of  the  gullet,  consists  of  a  raw  egg  broken 
into  a  cup,  seasoned  with  a  little  salt  and  vinegar,  and  swallowed 


143 


DISEASES  OF  THE  THROAT  AND  NOSE. 


whole  like  an  oyster.  The  yelk  f^enerally  breaks  at  the  moment  of 
swallowing,  and  thus  forms  an  agreeable  and  soothing  emollient 
application  to  the  throat,  at  the  same  time  that  it  is  a  valuable 
and  easily  digested  nutriment.  An  egg  can  frequently  be  swallowed 
in  this  way,  when  it  would  be  rejected  if  taken  beaten  up,  and 
spoilt  by  the  admixture  of  wine  or  milk.  In  cases  where  there 
is  a  return  through  the  nose  of  fluids  taken,  drinks  should  be 
thickened  with  arrowroot,  isinglass,  or  Iceland  moss,  and  the 
patient  should  be  directed  to  take  them  in  gulps  rather  than  in  sips. 

In  those  cases  where,  in  consequence  of  pyloric  obstruction, 
food  is  returned  after  a  greater  or  lesser  period  of  time,  much 
benefit  may  be  derived  by  predigestion  of  the  food,  by  means  of 
peptonizing  powders  or  pancreatic  extract.  The  casein  of  tha 
milk  or  the  albuminous  constituents  of  beef-tea  are  thus  easily 
converted  into  peptones,  and  absorption  in  the  stomach  is  thereby 
greatly  facilitated,  while  the  more  irritating  fermentative  pro- 
cesses are  held  in  check.  It  is  important  to  remember  that  food 
when  pancreatized  is  apt  to  quickly  putrefy. 

Artificial  Feeding. — Whenever  the  function  of  swallowing  is  so 
impaired  that  artificial  nutrition  is  necessary,  it  is  desirable,  if 
possible,  that  such  feeding  should  be  administered  through  the 
stomach  by  means  of  an  oesophageal  tube  rather  than  rectum. 
The  instrument  most  recently  introduced,  and  known,  I  think,  as 
Krishaber's,  is  an  immense  improvement  on  the  really  formidable 
weapon  usually  supplied  with  a  stomach  pump.  When  oeso- 
phageal feeding  is  adopted,  food  need  not  be  given  oftener  tluiii 
twice,  or  at  most  thrice,  in  the  twenty-four  hours.  The  same  may 
be  said  of  rectal  enemata.  Food  so  administered  should  be  pan- 
creatized, and  should  not  be  given  in  too  concentrated  a  form. 
There  can  be  no  doubt  that  much  harm  is  done  by  the  practice 
of  giving  essences  of  beef  or  milk  stronger  than  the  intention  of 
the  manufacturers.  In  our  experience  two  eggs,  with  six  or  eight 
ounces  of  good  beef-tea,  and  possibly  a  little  brandy,  as  well  as 
any  medicament  necessary  for  the  c:;se,  administered  twice  or  at 
most  thrice  daily,  constitute  an  all-efficient  diet  for  artificial  nutri- 
tion. The  food  should  be  given  at  a  temperature  of  go°  to 
100°  Fahr. 

When  the  obstruction  is  so  situated  as  to  offer  an  effectual 
barrier  to  the  introduction  of  food  into  the  stomach,  it  may  become 
necessary  to  consider  the  advisability  of  surgical  intervention 
with  a  view  of  preventing  a  painful  and  lingering  death  by  starva- 
tion. For  the  details  of  these  operations  the  reader  must  refer  to 
treatises  on  surgery. 

Respiratory.— Sudden  changes  of  temperature  are  aUvay^ 
hurtful  to  the  respiratory  passages.    Draughts  of  air  striking 


THERAPEUTICS  OF  THROAT  DISEASES. 


149 


against  the  throat  externalh^  or  a  very  sudden  change  of  breath- 
ing atmosphere,  particularly  if  just  after  use  of  the  voice,  are 
prone  to  set  up  congestion  of  the  larynx.  A  cold,  damp  atmo- 
sphere is  the  worst,  whereas  dry  winds,  even  if  cold,  are  often 
beneficial  rather  than  harmful,  as  the  experience  of  those  who 
have  tried  the  Davos-platz  in  the  Engadine  proves.  Warm, 
damp  south-west  wands,  though  agreeable  in  laryngeal  catarrh, 
are  often  hurtful  to  the  pharyngeal  relaxation,  which  induces, 
accompanies,  and  keeps  up  the  laryngeal  disease.  The  effect  of 
damp  on  the  discomforts  experienced  by  polypus,  and  by  many 
other  diseases  of  the  nose,  is  well  known. 

Our  great  object  in  advising  a  patient  on  climate  must  be  to 
change  the  particular  atmosphere  which  is  most  obnoxious.  If 
cold,  damp  air  is  hurtful,  warm  and  dry  inhalations  are  indicated, 
and  a  corresponding  change  of  residence.  My  own  opinion  of  the 
winter  health-resorts  of  England  is  not  a  favourable  one,  and  1 
beheve  that  if  the  patient  cannot  winter  at  his  own  home  with 
home  comforts,  or  in  London,  which  is  warmer,  drier,  and  better 
drained  than  any  small  town  can  be,  he  had  better  go  out  of 
England  altogether.  As  has  just  been  said,  ail  sudden  changes 
are  most  injurious,  and  it  does  not  much  matter  whether  the 
change  be  from  a  dwelling-house,  theatre,  church,  or  ball-room. 
[In  a  ball-room  there  is  superadded  to  the  change  of  temperature 
the  danger  of  inhaling  dust  and  actual  mineral  particles  from 
dresses,  artificial  flowers,  etc.  Many  patients  complain  of  throat- 
trouble  only  after  exposure  to  this  influence.]  With  regard  to 
change  of  clothing,  it  is  by  no  means  always  necessary  for  the 
patient  to  swathe  himself  in  flannel  ;  but  he  should  make  a  dif- 
ference, even  though  it  be  a  slight  one,  according  to  the  atmo- 
sphere, as  far  as  clothing  is  concerned.  There  is  no  country 
where  such  common-sense  precautions  are  less  heeded  than  in 
England,  and  none  where  they  are  more  necessary.  In  Russia, 
and  other  cold  countries,  all  outdoor  clothing  is  removed  the 
moment  the  wearer  enters  a  building.  These  remarks  are  equally 
applicable  to  the  reverse  practice  of  wearing  too  heavy  clothing 
in  hot  weather. 

Respirators  are  often  of  considerable  value  as  preventives 
against  cold  from  change  of  temperature,  and  are  useful  in  most 
cases  where  the  inhalation  of  unmitigated  atmosphere  causes 
irritation  of  the  throat.  When  a  patient  is  able  to  breathe 
entirely  through  the  nostrils,  a  respirator  is  of  but  little  use,  as 
Nature  has  provided  in  the  nasal  passages  an  efficient  respirator 
for  herself,  by  which  the  air  is  warmed  and  deprived  of  its 
noxious  properties  before  it  reaches  the  throat.  A  great  deal  of 
respiration  is,  however,  necessarily  carried  on  through  the  mouth, 


ISO  DISEASES  OF  THE  THROAT  AND  NOSE. 


especially  during  conversation,  and  it  is  under  such  circum- 
stances that  the  use  of  a  respirator  will  be  found  especially 
grateful  and  valuable.  The  principal  conditions  in  which  the 
respirator  is  useful  were  well  pointed  out  in  a  leading  article  in 
the  British  Medical  Journal,  March  3rd,  1877,  in  which  the 
following  remarks  occur :  *  In  fogs  the  black  carbonaceous 
particles  are  most  irritant  to  the  lining  membrane  of  the  air- 
tubes,  and  a  secretion  of  mucus  is  Nature's  method  of  sheathing 
the  tender  membrane  against  these  irritant  particles.  Many  of 
them  are  caught  on  the  sides  of  the  nasal  air-passages,  while 
others  become  entangled  in  the  mucus  of  the  bronchi  and 
bronchise,  as  is  evidenced  by  the  black  colour  of  the  expectorated 
phlegm.  In  such  fogs  many  of  those  who  do  not  resort  to 
respirators  will  be  found  with  their  handkerchiefs  over  their 
mouths,  converting  that  useful  article  into  a  makeshift  respirator. 
The  particles  are  largely  intercepted  by  the  respirator  in  transitu, 
and  still  more  if  the  respiration  be  carried  on  through  it  chiefly, 

and  but  to  a  small  extent  through  the  nostrils  The 

respirator  is  exceedingly  useful,  too,  under  the  following  circum- 
stances. In  cold  winds — especially  when  facing  them — the  cold 
air  finds  its  way  into  the  mouth  at  every  opportunity,  and  so 
communicating  with  the  air  respired,  or  with  the  residual  air  in 
the  thorax,  lowers  its  temperature,  and  then  hypersemia  of  the 
lining  membrane  of  the  air-tubes  is  produced.  The  respirator 
will  be  found  a  great  preservative  under  such  circumstances,  and 
will  prevent  many  a  cold,  sore  throat,  and  hoarseness.  In 
driving  in  cold  weather  it  will  be  found  to  be  very  comfortable  at 
the  time,  and  desirable  in  its  protecting  power  against  unpleasant 
after-effects  ;  also  in  walking  out  with  companions,  when  talking 
is  necessitated,  the  respirator  will  be  found  very  agreeable  by 
those  who  find  cold  air  so  breathed  to  produce  disturbance  in  the 
respiratory  apparatus.* 

Of  the  use  of  the  respirator  in  chronic  laryngitis,  Solis  Cohen 
thus  speaks :  '  Where  the  patient  is  exposed  to  the  inhalation  of 
irritant  gases  or  vapours,  or  solid  particles  floating  in  the  air,  he 
should  wear  a  respirator  at  the  time,  or  cover  the  nostrils  and 
mouth  with  a  veil,  or  keep  the  mouth  closed  and  protect  the 
nostrils  by  a  tiny  wad  of  cotton,  just  delicate  enough  not  to 
interfere  with  respiration.  Jn  some  cases  attended  with  frequent 
cough,  the  respirator  or  its  substitute  should  be  in  constant  requi- 
sition to  modify  the  effect  of  the  oxygen  of  the  air,  which  is  some- 
times too  irritating  for  the  over-sensitive  mucous  membrane. 
The  value  of  the  respirator  in  these  cases  cannot  be  appreciated 
by  those  who  have  not  witnessed  its  beneficial  effects  for  them- 
selves.*      -  - 


THERAPEUTICS  OF  THROAT  DISEASES. 


But  while  respirators  are  doubtless  of  service  to  many  persons, 
especially  females,  in  modifying  the  quality  and  temperature  of 
the  respired  air,  they  are  not  without  some  disadvantages.  They 
encourage  the  habit  of  breathing  by  the  mouth  in  preference  to 
the  nostrils,  the  result  of  which  at  night  is  a  liability  to  snore 
and  the  production  of  a  dry  mouth  and  fauces,  and  a  furred 
tongue ;  while,  during  the  day-time.  Nature's  contrivance  for 
warming  and  moistening  the  air  in  passing  through  the  narrow, 
winding  passages  of  the  nostrils  is  rendered  nugatory. 

Then  again,  the  very  susceptibility  of  the  mucous  membrane, 
to  mitigate  which  they  were  devised,  is  apt  to  be  increased  by  the 
unnatural  and  unnecessary  warmth  of  the  air  engendered  by  these 
instruments,  and  by  the  liability  to  take  cold  thereby  augmented. 

Finally,  a  certain  admixture  of  the  expired  wiih  the  inspired 
air  takes  place,  analogous  to  that  which  takes  place  in  an  im- 
perfectly ventilated  room. 

To  overcome  this,  an  oro-nasal  respirator  has  been  invented, 
but  it  is  very  unsightly.  Less  objectionable,  and  often  very 
serviceable,  is  a  simple  cloud  of  Shetland  wool  worn  over  mouth 
and  nose. 

The  drawback  of  unsightliness  already  mentioned,  and  one  of 
great  weight  with  ladies,  as  also  the  other  objections  to  the 
ordinary  respirator,  are  overcome  in  a  considerable  degree 
by  the  *  respirator-veil,'  which  was  suggested,  described,  and 
figured  by  me  in  the  British  Medical  Journal,  Nov.  i8th,  1876;  it 
consists  of  an  ordinary  piece  of  blonde,  about  twelve  inches  deep, 
over  the  lower  four  inches  of  which  is  sewn  a  double  thickness  of 
silk  gossamer.  By  wearing  this  as  a  veil,  mouth,  nostrils,  and 
ears  are  equally  and  sufficiently  protected  from  cold,  the  external 
atmosphere  being  warmed  in  the  chambers  formed  by  the 
layers  of  gossamer.  To  prevent  the  veil  from  becoming  un- 
pleasantly damp  by  the  moisture  of  the  breath,  that  part  which 
comes  over  the  nose  and  mouth  may  be  stiffened  by  a  layer  of 
wire-gauze,  so  as  to  stand  away  from  the  face,  and  it  may  be  pre- 
vented from  blowing  up  by  a  piece  of  elastic  braid  threaded 
through  the  lower  hem.  The  so-called  '  invisible '  respirators  are 
of  Httle  value,  except  for  compelling  nasal  respiration.  A  very 
ingenious  adaptation  of  the  respirator  to  remedial  purposes  has 
been  described  by  Sir  W.  Roberts,  of  Manchester,  under  the 
name  of  the  '  respirator  inhaler.'  In  appearance  it  much  re- 
sembles the  ordinary  respirator,  but  it  may  be  impregnated  with 
medicaments,  so  that  the  wearer  is  constantly  inhaling  a  medi- 
cated atmosphere.  The  unsightliness  of  the  ordinary  respirator 
has  been  somewhat  modified  by  Messrs.  Maw,  who,  instead  of 
the  ugly  and  conspicuous  black  cover  usually  adopted,  now  make 
some  of  their  respirators  with  drab  cloth,  which  renders  tha 


152 


DISEASES  OF  THE  THROAT  AND  NOSE. 


instrument,  especially  if  worn  under  a  thin  veil,  almost  imper- 
ceptible, or  at  least  less  unsightly. 

Vocal. — It  is  frequently  necessary  to  give  the  vocal  organs  rest, 
and  even  entirely  to  prohibit  the  use  of  the  voice,  especially  in 
the  case  of  those  patients  who  have  to  exercise  it  professionally. 
This,  however,  is  not  universally  the  case.  It  would  appear,  for 
instance,  that  reading  aloud,  and  talking  in  rattling  vehicles,  or 
in  noise  of  any  kind,  is  more  injurious  to  the  voice  than  public 
speaking.  Such  practices  should  therefore  be  strictly  forbidden. 
Again,  many  singers  complain  of  diminished  range,  both  in  their 
lower  and  higher  notes,  without  there  being  any  perceptible  im- 
pairment  of  the  middle  register.  In  these  circumstances  directions 
for  the  modified  use  of  the  voice  are  indicated,  and  particular 
attention  is  required  in  order  to  ascertain  whether  the  defect  in 
the  voice  may  not  be  due  to  faulty  voice  production.  This 
subject  having  been  elsewhere  treated  at  some  length,  it  is  not 
necessary  here  to  do  more  than  refer  to  it. 

Where  there  is  spasmodic  vocal  enunciation,  or  where  there  is 
the  slightest  ulceration  or  abrasion  of  the  vocal  portion  of  the 
larynx,  absolute  silence  must  for  a  time  be  enjoined. 

Baineo-Therapeutics. — The  benefit  to  be  derived  from  treat- 
ment of  disease  by  the  aid  of  natural  waters  is  by  no  means  so 
highly  appreciated  by  practitioners  in  England  as  abroad.  One 
reason  for  this  incredulity  may  doubtless  be  found  in  the  fact  that, 
while,  perhaps,  too  much  is  claimed  for  hydrotherapeutics  by  our 
Continental  confreres,  the  results  of  treatment  by  those  springs 
which  we  possess  in  England  have  not  so  far  encouraged  practi- 
tioners to  extend  their  experience.  Within  the  last  few  years, 
however,  great  advance  has  been  made  in  this  branch  of  treat- 
ment, and  it  is  proved  beyond  doubt  that  the  action  of  natural 
mineral  waters  does  not  depend  solely,  or  even  to  any  great 
extent,  on  the  amount,  often  very  small,  of  active  ingredient  which 
they  contain,  but  is  the  result  of  their  natural  chemical  combina- 
tion, and  of  their  thermal  properties.  It  is  this  last  principle  of  a 
natural  high  temperature  that  is  to  be  found  in  almost  every 
water  of  any  value  for  bath  treatment,  especially  of  those  suited 
to  diseases  of  the  larynx.  In  all  the  effect  is  produced  not  only, 
and  often  not  at  all,  by  their  local  action,  but  by  their  eliminative 
action  on  the  skin,  the  kidneys,  liver,  etc.  Moreover,  as  regards 
the  throat,  the  circumstance  that  '  spa  cures  '  are  for  the  most 
part  undertaken  in  the  summer  is  not  to  be  ignored  as  an  impor- 
tant adjuvant  of  the  therapeutic  value  of  the  particular  spring 
selected.  For  the  same  reason  this  treatment  is  unattainable  at 
that  season  of  the  year  when  the  patient  is  most  likely  to  require 
relief  for  acute  exacerbations,  the  establishments  being  almost  uni- 


THERAPEUTICS  OF  TU/WAT  DISEASES. 


'53 


versally  closed  in  the  winter  months ;  and  in  this  respect  the 
waters  of  Bath  possess  unique  advantages  over  Continental 
sources,  though  it  is  possible  that,  in  some  cases,  exposure  of  the 
bather  to  inclement  weather  may  in  turn  negative,  or  at  least  go 
far  to  discount,  the  benefit  which,  per  se,  the  waters  are  capable  of 
effecting.  An  unsigned  article  in  the  Journal  of  Laryngology  for 
November,  1887,  gives  in  a  few  pages  very  full  information  on 
those  springs  best  adapted  to  diseases  of  the  throat  and  nose. 
They  may  be  broadly  classified  as  follows  :  (i)  The  Sulphurous, 
containing  free  HgS,  and  combinations  of  sodic  and  calcic  sul- 
phides. It  is  doubtful  whether  sulphur-baths  have  any  action 
other  than  that  of  perfectly  indifferent  thermae.  The  effect  of 
sulphuretted  water  as  sprays  is  hardly  more  potent  than  the 
baths— tney  are  rather  sedative  when  so  employed.  But  sul- 
phur waters  taken  internally  have  a  powerful  effect  in  reducing 
hepatic  engorgements,  and  congestive  conditions  of  the  gastro- 
intestinal tracts,  and  also  for  catarrhal  conditions  of  mucous 
membranes,  particularly  the  respiratory.  Of  sulphur-springs, 
those  chiefiy  to  be  recommended  are  Aix-les-Bains,  Luchon,  and 
Cauterets  for  bathing,  Challes  for  drinking,  and  Marlioz  for  spray 
inhalations.  Both  Challes  and  Marlioz  are  situated  very  near  to 
Aix-les-Bains — which  is  also  to  be  recommended  by  preference, 
on  account  of  the  great  abundance  of  the  supply  of  water  (one 
million  gallons  per  day),  and  for  perfection  of  every  detail  of  the 
bath  establishment.  The  waters  of  Bath  have  many  points  of 
similarity  to  those  of  Aix-les-Bains — are  very  abundant,  and  are 
administered  in  great  perfection.  Every  detail  of  treatment  as 
pursued  at  Aix  is  to  be  found  here,  even  to  the  employment  of 
masseurs  and  masseuses  from  Savoy.  (2)  The  Saline,  charac- 
terised chiefly  by  the  presence  of  sulphates  and  chlorates.  Those 
rich  in  chlorides  are  the  most  valuable  for  throat  and  pulmonary 
complaints,  and  can  be  employed  either  as  '  brine  baths,'  or  inter- 
nally as  potions.  Soden,  in  Germany,  has  a  high  repute,  but  of 
it  I  have  no  personal  experience.  Mont  Dore,  Royat,  Aix,  Wies- 
baden, and  Homburg  have  each  a  high  reputation.  At  Mont 
Dore,  and  more  especially  at  Bourboule,  close  to  it,  much  of  the 
benefit  derived  is  due  to  the  arsenic  contained  in  the  waters, 
which  are  of  service  in  cases  of  granularpharyngitis,  enlargements  of 
the  bronchial  glands,  and  in  some  forms  of  asthma.  At  Kreuznach, 
Challes,  and  also  at  Woodhall  Spa  in  Lincolnshire,  the  waters  are 
strongly  impregnated  with  bromo-iodine,  and  are  indicated  in  cases 
of  scrofulous  enlargement  of  the  l}  mpl)atic  glands,  and  in  goitrous 
and  other  tumours.  The  waters  which  contain  iron  are  legion, 
and  cannot  here  be  enumerated.  Of  simple  alkaline  waters,  Ems 
is  by  far  the  most  generally  serviceable. 


CHAPTER  VIII. 


THE  GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  THROAT 

DISEASES. 

It  may  be  generally  accepted  that  the  throat  is  liable  to  become 
the  seat  of  any  pathological  change  peculiar  to  the  many  and 
varied  structures  which  make  up  its  component  parts.  Every 
known  morbid  process  of  cartilage,  mucous  membrane,  sub- 
mucous and  glandular  tissue,  arteries,  nerves,  or  muscles,  singly  or 
together,  may  be  observed  in  the  larynx  or  pharynx. 

To  quote  ^  Cohen:  *  Inflammations,  idiopathic,  deuteropathic 
and  traumatic,  occur  in  various  grades,  or  occur  as  constituent 
manifestations  or  results  of  systemic  affections,  such  as  tuber- 
culosis, scrofulosis,  syphilis,  cancer,  rheumatism,  gout,  erysipelas 
and  the  exanthemata,  continued  fevers,  diseases  of  the  large 
glands,  chronic  cutaneous  affections,  and  other  maladies.  Then 
we  encounter  the  various  products  of  inflammation — adhesions  of 
tissues,  fistulse,  strictures,  glandular  enlargements,  tumours  benign 
and  mahgnant,  aneurisms,  etc. ;  likewise  wounds  and  other  local 
injuries,  mechanical  and  chemical;  foreign  bodies,  introduced  by 
accident  or  design ;  local  results,  such  as  oedema,  pustular  inflam- 
mation and  destructive  ulceration  from  the  use  of  certain  drugs, 
....  and  finally,  various  disorders  of  nervous  origin.' 

It  is  not,  of  course,  intended  to  discuss  in  this  chapter  the 
causation  and  pathological  nature  of  all  throat  diseases,  but  only 
to  draw  attention  to  some  main  facts  which  underlie  the  general 
question  of  diseases — and  especially  of  inflammation  in  the  rhino- 
pharyngo-laryngeal  tract. 

M^ny  influences  combine  lo  intensify  or  to  modify  diseases  of 
the  throat,  and  so  complex  are  they  that  it  is  quite  impossible  in 
a  general  consideration  of  the  subject  to  entirely  separate  them 
by  any  regular  method.  For  exam.ple,  disorders  of  respiration 
may  arise  from  causes  which  will  also  influence,  in  a  more  or  less 
marked  degree,  the  functions  of  deglutition  and  vocalization  ;  or 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  15s 


each  of  all  these  processes  may  be  impaired  separately  and  with- 
out any  effect  on  the  other.  In  certain  circumstances  the 
pharynx,  or  some  portion  of  it,  may  be  primarily  attacked,  in 
others  the  larynx.  In  one  person  a  pharyngeal  disease  may 
extend  upwards  towards  the  nares,  in  another  downwards  to  the 
larynx.  Similarly  the  local  manifestations  of  systemic  diseases 
may  be  exhibited  in  quite  different  parts  of  the  throat,  and  it  is 
difficult  always  to  assign  causes  for  these  varied  peculiarities. 
Without  continuing  to  generalize,  it  may  be  said  that  from  what- 
ever point  of  view  we  consider  the  causation  and  character  of 
throat  diseases — the  anatomical,  the  bacteriological,  the  func- 
tional, or  the  general  hygienic  —  we  shall  encounter  these 
difficulties,  and  an  attempt  to  clear  our  ground  of  some  of  them 
before  entering  into  examination  of  each  individual  throat  disease, 
can  only  be  successful  if  we  acknowledge  at  starting  that  we  must 
not  restrict  ourselves  to  any  one  aspect  of  the  task. 

In  any  general  summary  of  the  etiology  and  patholog}'  of  mor- 
bid conditions  of  this  region,  we  have  necessarily  to  take  into 
account : 

1.  The  secretory  and  absorbent  processes  of  the  throat,  includ- 

ing (a)  the  nature  of  the  secretions  in  health  and  in 
diseased  states ;  and  (6)  the  character  of  the  fluids 
absorbed,  both  normal  and  pathological. 

2.  The  respiratory  functions  of  the  various  parts  of  the  throat 

(a)  in  health,  and  {b)  as  modified  abnormally  by  structural 
changes  or  circumstance,  e.g.,  insanitary  surroundings,  etc. 

3.  The  throat,  as  part  of  the  alimentary  tract. 

4.  The  throat  in  relation  to  voice-production. 

5.  The  pathological  results  of  the  above  departures  from  normal 

function. 

Before  even  endeavouring  to  throw  into  relief  the  more  obvious 
factors  which  obtain  in  the  commonest  forms  of  throat  disease  it 
is  necessary  to  anticipate  somewhat,  and  to  draw  attention  to  the 
connection  between  morbid  conditions  of  the  throat  and  those  of 
the  nose.  If  the  nose  be  obstructed,  its  important  respiratory 
functions  of  warming,  moistening,  and  filtering  the  air,  have  to  be 
carried  on  under  disadvantageous  circumstances  by  the  mouth, 
pharynx,  and  larynx,  and  a  departure  from  the  healthy  condition 
of  these  parts,  in  relation  to  all  the  functions  just  enumerated, 
ensues  sooner  or  later ;  for  it  is  now  all  but  universally  recognised 
that  a  majority  of  diseases  of  the  pharynx,  larynx,  and  tympanum 
are  directly  related  to  obstructive  disorders  of  the  nose.  Nasal 
stenosis,  whatever  its  cause,  leads  to  mouth-breathing,  with  its 


156 


DISEASES  OF  THE  THROAT  AND  NOSE. 


attendant  evils ;  and  in  not  a  few  instances  of  pharyngitis  and 
laryngitis  the  sole  indication  for  treatment  is  to  remedy  the  nasal 
obstruction.  Much  literature  has  lately  appeared  on  this  impor- 
tant subject  of  mouth-breathing,  the  most  recent  and  valuable 
being  the  monograph  of  ^Bloch,  the  pupil  and  successor  of  the 
lamented  Hack. 

Of  equal  importance,  almost,  in  the  etiology  of  throat  diseases, 
stands  the  character  of  the  nasal  and  buccal  secretions.  So  long  as 
the  nasal  respiratory  channels  are  normal  and  the  secretions  from 
the  nose,  mouth  and  throat  healthy,  so  long  will  the  individual  be 
likely  to  escape  ordinary  throat  troubles.  It  is  necessary  to  bear 
in  mind  that  the  nasal  and  oral  fluids  are  continually  being  con- 
taminated extrinsically  by  the  entrance  of  germs  and  irritants  in 
the  air,  and  intrinsically  by  diathetic  states  of  the  system  ;  and 
herein  lies  the  importance  of  a  knowledge  of  bacteriology. 

It  has  to  be  remembered  that  the  throat  is  lined  by  a  mucous 
membrane  which  is  both  highly  secretory  and  absorptive  ;  and  it 
is  probable  that  in  health  the  secretory  function  is  of  far  more 
importance  to  the  organism  than  the  absorptive.  Attention  has 
already  been  called  to  the  two  kinds  of  glands  of  the  throat,  the 
acinous  and  the  lymphoid  :  the  former  are  concerned  principally 
with  the  secretion  of  a  lubricating  substance — mucus — and  they 
are,  therefore,  pretty  widely  disseminated  over  the  whole  mucous 
lining.  The  function,  however,  of  the  lymphoid  glandular  tissues 
has  been  long  a  matter  of  speculation  and  conjecture,  though 
their  great  development  in  this  region,  and  especially  in  the 
pharynx,  has  evidently  pointed  to  some  very  important  duty. 
We  have  already  alluded  to  these  lymphoid  glands,  which,  when 
aggregated,  are  known  as  tonsils,  a  term  until  recently  restricted 
to  the  faucial  lymphoid  masses,  but  now  applied  to  the  aggrega- 
tions of  adenoid  tissue  in  the  roof  of  the  naso  pharynx,  at  the  Eus- 
tachian orifices,  at  the  base  of  the  tongue,  in  the  soft  palate,  and 
in  the  ventricle  of  the  larynx,  and  known  respectively  as  the 
pharyngeal,  tubal,  lingual,  palatal  and  laryngeal  tonsils.  More- 
over, the  disseminated  lymphoid  follicles  at  the  back  of  the  oro- 
pharynx have  been  named  the  discrete  tonsil  ;  this  nomenclature 
is  doubtless  open  to  criticism,  but  is  now  so  generally  adopted  by 
specialists  at  home  and  abroad,  that  no  apology  is  necessary  for 
taking  advantage  of  it  on  the  ground  of  convenience.  Although 
the  importance  of  these  lymphoid  glandular  structures  has  been 
recognised  on  anatomical  and  clinical  grounds,  it  is  only  during 
the  last  few  years  that  the  question  of  their  function  has  been 
seriously  treated.  The  older  writers  vaguely  regarded  the  tonsils 
as  having  some  lubricating  function.    In  more  recent  times  they 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  i 


have  been  rightly  referred  to  the  lymphatic  system,  becan<-e  of 
their  obvious  structural  resemblance  to  the  ordinary  lymphatic 
glands.    Their  raison  d'etre  on  the  walls  of  the  alimentary  and 
respiratory  tracts,  however,  still  remained  unexplained  ;  it  had 
always  appeared  evident  to  me  that  their  situation  indicated  some 
function  added  to  that  of  their  prototype — the  leucocyte  manu- 
facturing lymphatic  gland.    In  the  second  edition  of  this  work  I 
called  attention  to  the  speculations  of  ^  Kingston  Fox,  who  endea- 
voured to  show  that  the  tonsils  were  absorptive  in  function,  he 
arguing  from  the  observed  fact  that  inflammatory  conditions  of 
the  tonsils  are  nearly  always  in  relation  with  abnormal  states  of 
the  buccal  fluids.    Recognising  the  importance  of  obtaining  more 
definite  information  as  to  the  role  of  the  tonsillar  tissues,  I,  in 
1886,  suggested  to  my  former  pupil,  Mr.  William  Hill,  the  advis- 
abihty  of  utilizing  the  opportunities  afforded  by  the  Throat  and 
Ear  Hospital  for  the  purpose  of  settling  some  disputed  points. 
As  the  result  of  these  investi*gations,  ^Hill  finds  that  the  tonsils, 
whilst  receiving  the  products  of  absorption  through  the  lymphatics 
of  the  neighbouring  mucous  membrane,  and  perhaps  directly 
absorbing  by  their  epithelial  covering,  are  in  the  main  manufac- 
turers and  secretors  of  leucocytes.    The  crypts,  when  present, 
which,  according  to  Fox,  facilitate  absorption,  are,  it  is  contended, 
more  allied  to  ducts,  being  *  reservoirs '  for  leucocytes,  which 
migrate  through  the  mucous  membrane,  by  diapedesis,  into  them 
from  the  lymphoid  saccules,  or  follicles.    On  this  view  the  lining  of 
the  nose  and  throat,  whilst  highly  absorbent,  like  any  other 
mucous  surface,  possesses  two  distinct  sets  of  secretions  and 
secretory  mechanisms,  viz.,  the  acinous  glands  which  secrete  a 
mucous  lubricating  fluid,  and  the  lymphoid  (tonsillar)  glands, 
which  secrete  lymph.    The  leucocytes  in  the  latter  fluid  probably 
act  as  '  scavengers,'  devouring  germs,  small  particles  of  food,  etc., 
and  possibly  playing  also  some  important  role  in  amyolitic  diges- 
tion.   Fox's  views  as  to  the  connection  between  lymphoid  inflam- 
mations in  the  throat,  and  contaminated  condition  of  the  nasal 
and  oral  fluids  are  confirmed. 

^Retterer,  as  the  result  of  elaborate  researches  into  the  develop- 
ment and  structure  of  the  tonsils,  has  come  to  the  conclusion 
that  they  are  secreting  glands  ;  but  he  has  fallen  into  the  error  of 
stating  that  they  have  no  ducts,  and  therefore  conjectures  that 
the  products  of  secretion  pass  only  to  the  blood  system.  He  has 
curiously  missed  the  point  that  the  crypts  are  potential  ducts,  and 
that  leucocyte  secretion  is  by  diapedesis  through  the  mucous 
covering  into  the  cryptic  diverticula. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


These  views  being  conceded,  it  is  evident  that  nasal  obstruction, 
as  leading  to  mouth-breathing,  is  an  important  factor  in  the  pro- 
duction of  unhealthy  states  of  the  buccal  secretions,  and  that 
irritating  products  in  these  fluids,  interfering  with  the  proper 
performance  of  function  of  the  lymph-secreting  follicular  glands, 
are  a  fruitful  source  of  disease. 

As  regards  the  etiology  of  faucial  and  naso-pharyngeal  lym- 
phoid inflammation,  ^Hill  has  shown  it  to  be,  for  instance,  a  fact 
that  most  forms  are  associated  with  either  (a)  extrinsic,  usually 
septic,  microbic  influences,  which  contaminate  the  contents  of 
the  oral  cavity,  or  (6)  with  intrinsic  influences,  usually  associated 
with  some  diathetic  state  in  which  the  buccal  secretions  contain 
abnormal  irritating  products.  Amongst  the  oral  contaminations 
of  an  extrinsic  character  may  be  mentioned  impure  food,  water, 
and  especially  impure  air,  dependent  on  insanitary  surroundings, 
and  particularly  to  the  presence  of  micro  organisms  of  a  patho- 
genic or  quasi-pathogenic  character.  Mycosis  tonsillaris,  and  the 
tonsillitis  of  scarlet  fever,  diphtheria,  etc.,  may  be  instanced  as 
evidently  of  extrinsic  origin. 

Again,  the  chronic  hypertrophic  inflammatory  conditions  of 
the  pharynx  met  with  in  individuals  the  subjects  of  the  strumous 
diathesis  and  of  syphilis  are  examples  of  intrinsic  contaminations 
of  the  buccal  secretions.  In  many  instances  of  pharyngitis,  how- 
ever, we  find,  that  to  an  intrinsic,  often  chronic  diathetic  predis- 
position to  inflammation,  there  is  often  added  an  exciting  factor, 
such  as  cold  or  wet,  which  induces  catarrh,  a  condition  the  causes 
of  which  will  be  presently  explained  as  resulting  from  the  growth 
and  pathogenic  changes  of  micro-organisms.  Most  forms  of 
tonsillitis  and  pharyngitis  appear  to  be  readily  explicable  on  a 
similar  basis. 

In  former  editions  of  this  book  attention  has  been  drawn  to 
the  influence  of  these  micro-organisms  as  primary,  or  at  least  as 
exciting,  causes  of  disease  in  the  nose  and  throat.  But  the  sub- 
ject was  treated  almost  entirely  from  an  expectant  point  of  view. 
In  the  meantime  the  science  of  bacteriology  has  become  suffi- 
ciently established  for  us  to  discuss  this  important  question  from 
a  more  definite  standpoint,  and  we  are  now  in  a  position  to 
weigh  the  evidence,  which  shall  decide  the  relation  of  micro- 
organisms to  certain  specific  diseases. 

In  the  region  of  the  nose,  throat  and  upper  air-passages  we 
have  an  unequalled  human  field  of  observation  of  micro-organisms. 
This  must  be  evident  when  we  consider  that,  of  all  parts  of  the 
body  the  upper  air-passages,  in  the  simple  pursuance  of  their 


ETIOLOG  V  AND  PA  THOLOG  V  OF  THRO  A  T  DISEASES.  159 


physiological  duties,  are  recipients  of  the  myriads  of  various 
germs  which  are  constantly  floating  in  the  surrounding  atmo- 
sphere. 

Several  investigators  have  done  splendid  work  in  this  depart- 
ment, and  diagnosis  has  been  materially  aided  by  the  careful 
observation  and  record  of  the  various  forms  of  bacteria  which 
can  be  found  in  the  cavities  of  the  mouth,  nose,  and  upper  air- 
passages. 

^Miller,  of  Berlin,  has  described  over  twenty  different  micro- 
organisms in  the  mouth  alone;  Vignall  and  Wright  have  con- 
firmed his  evidence,  and  have  even  added  to  their  number.  ^John 
Macintyre,  in  a  series  of  admirable  and  exhaustive  papers  read 
before  the  British  Laryngological  and  the  Medical  Associations, 
has  rendered  great  service  to  the  science  of  bacteriology  in 
general,  and  has  added  a  vast  amount  to  our  knowledge  of  the 
special  subject  of  micro-organisms  which  are  related  to  the  pro- 
duction of  diseases  in  the  regions  under  present  consideration. 
He  proves  that  the  oral  cavity  at  least  is  the  gathering-place  and 
site  of  incubation  for  myriads  of  the  pathogenic  bacteria,  and 
that  many  diseases,  if  traced  to  their  source,  will  be  found  to 
originate  in  the  mouth  and  upper  air-passages. 

Among  the  many  diseases  whose  origin  have  thus  been  ascer- 
tained may  be  mentioned  dental  caries,  stomatitis,  thrush,  aphtha, 
herpes  labialis,  pneumonia,  actinomycosis,  noma,  diphtheria, 
syphilis,  tubercle,  ozoena,  etc.  Under  ordinary  cirr^umstances 
the  upper  air-passages  and  their  cavities  perform  the  function 
of  a  filter  of  germ-laden  air,  by  far  the  greater  number  of  the 
inhaled  micro-organisms  becoming  thereby  lodged  in  the  oral, 
nasal,  and  pharyngeal  cavities,  from  which  they  are  carried  by  deep 
inspiratory  efforts  into  the  bronchial  tubes  and  into  the  alveoli  of 
the  lungs.  The  probability  that  the  mouth  forms  a  gathering 
and  breeding  place  for  these  bacteria  is  supported  by  the  fact 
that  the  coccus  of  pneumonia  cannot  develop  at  the  ordinary 
temperature  of  the  air,  and  that  its  virulence  is  lost  when  it  is 
cultivated  outside  the  body.  A  number  of  pathogenic  bacteria 
appear  to  be  able  to  live  for  a  considerable  length  of  time  in 
the  mouth,  as,  for  instance,  those  of  diphtheria,  tubercle  and 
syphilis. 

Why  these  organisms,  which  normally  exist  in  the  mouth,  do 
not  always  cause  pathological  conditions  is  no  doubt  materially 
due  to  phagocytosis,  and  to  the  further  fact  that  the  inflammatory 
changes  which  are  often  set  up  in  the  mucous  membranes 
exercise  a  defensive  action  in  the  invaded  regions. 


i6o 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  presence  of  these  pathogenic  organisms,  whose  Hfe-pro- 
cesses  are  at  one  time  benignant,  and  at  another  time  mahgnant, 
in  the  sense  of  being  inimical  to  the  healthy  condition  of  the 
mouth  and  throat,  and  to  the  individual  generally,  has  only  in 
recent  years  been  fully  realized.  In  this  group,  members  of  which 
may,  in  small  numbers,  inhabit  the  healthy  mouth,  must  be 
included  leptothrix  buccalis,  which  under  certain  circumstances 
appears  to  produce  mycosis  tonsillaris  and  so-called  follicular 
pharyngitis ;  also  the  diplococcus  of  Frankel,  and  the  pneumo- 
coccus  of  Friedlander,  which  seem  to  be  so  intimately  associated 
with  febrile  pneumonic  conditions ;  also  staphylococcus  albus 
and  aureus,  and  streptococcus  pyogenes,  which  are  general  con- 
comitants of  suppurating  processes  in  the  mouth  and  elsewhere. 
Netter  demonstrated  that  diplococci  and  pneumococci  are  some- 
times present  in  healthy  saliva,  but  Miller  and  Macintyre  have 
since  proved  that  they  are  constant  even  in  individuals  exhibiting 
no  deviation  from  the  normal.  These  organisms  are,  according  to 
the  latter  observer,  responsible  for  what  has  been  hitherto  known 
as  the  catarrhal  condition.  Furthermore,  the  life-processes  of  oral 
and  pharyngeal  colonies  of  such  microbes  may  be  the  starting- 
point  of  zymotic  febrile  diseases,  as  for  instance  scarlet-fever^ 
measles,  or  small-pox,  in  which  probably  the  germs,  together 
with  their  poisonous  chemical  excreta,  gain  access  to  the  blood- 
system,  or,  as  in  diphtheria,  where  the  chemical  poison  alone 
enters  the  system,  the  germinating  organisms  remaining  on  the 
false  membrane. 

Mention  has  been  made  of  the  chemxal  life-processes  of  micro- 
organisms. There  have  been  identified  and  cultivated  from  the 
human  mouth  between  50  and  100  different  micro-organisms,  a 
third  of  which  have  been  considered  of  a  pathogenic  or  quasi- 
pathogenic  character.  Unfortunately  the  pathogenic  nature  of 
many  of  them  has  been  inferred  from  the  morbid  effects  produced 
on  rabbits,  mice,  and  other  small  animals  injected  with  the  bac- 
teria-adulterated saliva,  and  the  fact  that  in  many  instances  the 
blood  and  tissues  of  these  inoculated  animals  swarmed  with  the 
same  organisms  which  the  salivary  injection  contained,  has  been 
held  to  prove  the  pathogenic  nature  of  the  organism  in  question. 
Such  a  test,  however,  scarcely  estabHshes  the  pathogenic  nature 
of  a  microbe  in  relation  to  the  human  subject,  which  is  the  point 
of  practical  importance ;  and,  moreover,  the  fact  that  small 
animals  often  die  after  injection  with  morbid  salivary  secretions 
without  the  reproduction  of  the  organism  supposed  to  be  patho- 
genic, although  held  to  prove  that  the  microbic  life-processes  ha^  ,^ 


ETIOLOGY  AND  PATHOLOGY  OF  TIJROAT  DISK 


produced  a  chemical  poison  (ptomaine,  albumin,  albumose,  6 
what  not)  inimical  to  the  life  of  the  animal  experimented  upon,  by 
no  means  necessarily  leads  to  the  inference  that  the  poison  is  of 
any  pathogenic  importance,  as  regards  the  human  organism, 
when  present  in  the  buccal  fluids.  Indeed,  our  knowledge  of  the 
part  played  by  bacteria  in  the  human  mouth,  throat,  and  alimen- 
tary tract,  though  increasing,  is  still  very  imperfect. 

^  The  subject  has  been  very  fully  considered  from  the  point  of 
view  of  the  scientific  dentist  by  ^Cunningham. 

As  is  well  known,  one  or  two  oral  bacteria  possess  the  power  of 
converting  starch  into  sugar  ;  the  majority  are  able  to  invert  cane- 
sugar  into  levulose  and  dextrose,  and  a  large  number  possess  the 
power  of  changing  sugar  into  lactic  acid.    (CcHi.Og  grape  sugar  = 
2C3H6O3  lactic  acid.) 

Carbonic  dioxide,  hydrogen,  formic,  butylic,  and  acetic  acids  are 
also  formed  in  the  mouth  by  bacterial  action.    Of  all  these 
chemical  processes  it  is  probable  that  the  production  of  lactic 
acid  is  of  chief  pathological  and  etiological  importance.  Dental 
surgeons  believe  that  these  acid  contaminations  of  the  buccal 
cavity  of  bacterial  origin,  and  especially  the  lactic  acids,  bring 
about  decalcification  of  the  teeth,  and  the  animal  part  of  the 
dental  framework  is  afterwards  dissolved  by  virtue  of  the  pepto- 
nizing power  which  ceii:ain  buccal  and  other  micro-organisms  are 
known  to  possess.    We  know  something  also  of  the  habits  and 
methods  of  acute  pathogenic  bacteria  in  the  mouth  and  throat. 
Many  of  them  produce  an  enzyme  or  ferment  which  acts  on  the 
surrounding  organic  media,  producing  numerous  poisons.  Our 
knowledge  here  again  is,  however,  very  imperfect.    It  has  been 
proved  for  instance,  in  the  case  of  pharyngo-laryngeal  diphtheria, 
a  specific  bacterial  disease,  that  the  ferment  by  its  action  produces 
in  the  surrounding  media  a  highly  poisonous  alkaloid  which  was 
isolated  by  i«Roux  and  Yersin  (1888).    This,  when  injected  into 
an  animal,  will  produce  the  characteristic  symptoms  of  paralysis, 
syncope,  etc.    From  this,  therefore,  it  is  concluded  that  it  is  not 
the  mere  presence  of  the  microbe  which  causes  the  symptoms,  but 
the  consequent  production  of  a  poison,  which  enters  the  system 
and  produces  a  toxic  result,  a  conclusion  which  is  confirmatory 
of  the  Ptomaine  theory  of  this  disease,  which  I  advanced  in  my 
second  edition,  pubHshed  early  in  1887.    Under  some  conditions 
pathogenic  organisms  are  capable  of  forming  poisonous  alkaloidal 
bodies  or  ptomaines,  besides  virulent  albumins,  albumoses,  and 
acids.   Apart  from  Gautier's  researches,  these  substances  have  not 
been  looked  for  to  any  extent  in  the  mouth  and  pharynx  under 


l62 


DISE ASICS  OF  THE  THROAT  AND  NOSE. 


diseased  conditions.  This  will  doubtless  in  the  near  future  form 
a  fertile  field  for  a  microbic  and  chemical  investigation. 

Associated  with  most  disorders  of  the  throat,  we  get  either  exces- 
sive or  diminished  capillary  circulation — hypersemia,  or  anaemia — 
with  a  tendency  to  hypertrophy  or  atrophy,  temporary  or  perma- 
nent, of  the  submucous  tissue.  These  changes  constitute  the  con- 
dition known  as  catarrh,  which  may  be  acute  or  chronic,  and  may 
result  in,  or  be  complicated  by,  infiltrations,  abrasions,  erosions, 
ulcerations,  and  new  formations.  When  the  inflammation  of  the 
mucous  membrane  is  acute,  the  exudations  may  be  of  a  more 
intense  character,  and  these  may  be  of  two  kinds,  the  one  from 
the  surface,  which  was  known  formerly  as  croupous  or  fibrinous ; 
the  other  interstitial  and  leading  to  ulceration,  which  is  denomi- 
nated diphtheritic. 

A  fashion  has  lately  obtained  of  considering  all  such  exudations 
as  diphtheritic,  but  I  have  long  urged  that  it  is  a  mistake  thus  to 
merge  terms  very  distinctive  in  signification ;  and  here  again  I 
am  confirmed  in  my  contention  by  recent  investigations. 

That  diphtheria  is  a  specific  disease  depending  on  the  presence 
of  certain  micro-organisms  has  long  been  known.  Klebs,  of 
Wiesbaden,  in  1833  detected  these  microbes  in  the  membrane 
from  the  throats  of  those  suffering  from  that  disease.  His 
observations  were  confirmed  by  Loffler,  and  the  micro-organism 
described  as  the  Klebs-Loffler  bacillus.  Those  recent  investiga- 
tions have  added  much  to  our  knowledge  of  the  etiology  of  this 
disease. 

^^Klein  has  shown  that  the  Klebs-Loffler  bacillus  is  constantly 
present  in  the  true  diphtheritic  membranes ;  but,  besides  this 
bacillus,  other  forms  of  bacteria,  viz.,  streptococci,  have  been 
found  to  be  very  frequently,  if  not  constantly,  present  in  the 
membranes.  These  have  been  described  by  Prudden,  D'Espine, 
Fehleison,  and  quite  r.  cently  by  ^'^Ruault,  of  Paris.  These  cocci 
when  inoculated  in  animals  produce  local  inflammations,  but  not 
false  membranes.  They  are  also — and  this  is  most  important  to 
note— found  in  the  blood  and  viscera  of  the  animals  so  inocu- 
lated ;  while,  on  the  contrary,  the  Klebs-Lofiier  bacillus  is  never 
found  in  the  blood  or  viscera  when  similarly  infected. 

Klebs  therefore  concludes  that  there  are  two  forms  of  diph- 
theria, and  is  supported  in  this  conclusion  by  Roux  and  Yersin, 
Ruault,  and  others.  These  observers  state  that  the  formation 
of  membrane  depends  on  the  specific  bacillus,  but  the  toxic 
symptoms— paralysis,  etc. — depend  on  the  poison  produced  by 
them,  and  that  the  secondary  infections  depend  on  the  presence 
of  micrococci  which  accompany  the  Klebs-Loffler  bacillus.  . 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  163 


Ruault  describes  two  forms  of  diphtheria,  which  he  calls 
(i)  monomicrobian,  or  bacillary,  in  which  the  Klebs-Loffler 
bacillus  alone  is  present,  and  in  which  form  of  the  disease  the 
fever  is  slight,  throat  affection  not  severe,  and  the  submaxillary 
glands  are  swollen,  and  albuminuria  slight  or  absent.  In  the 
second  form,  the  polynnicrohian,  micrococci  are  present  as  well 
as  bacilla.  Ruault  describes  two  forms  of  polymicrobian,  one 
in  which  cocci,  and  the  other  streptococci,  are  present. 

To  the  cocco-bacillary  form  he  considers  the  secondary  diph- 
theria of  scarlet  fever,  measles,  whooping-cough  to  belong. 
^^Thorne-Thorne  thinks  that  the  lesion  in  the  mucous  membrane 
after  scarlet  fever  constitutes  a  favourable  soil  for  diphtheritic 
contagion,  and  that  this  explains  the  relation  between  them,  if 
any  really  exists. 

^^Gottstein  and  others  apply  the  word  '  secondary  diphtheria  ' 
to  the  membranous  laryngitis  which  often  complicates  the  course 
of  the  exanthemata,  continued  fevers,  erysipelas,  etc.  ;  but  it  need 
hardly  be  pointed  out  that  the  value  of  the  word  '  diphtheria  '  is 
deprived  of  much  valuable  diagnostic  significance  if  it  be  applied 
indiscriminately  to  the  development  of  the  exudative  process  when 
occurring  in  the  case  of  a  laryngeal  inflammation  of  an  etiology 
totally  different  from  that  usually  ascribed  to  the  primary  disease, 
and  characterized  by  many  distinctive  phenomena.  In  view  of 
the  recent  facts  above  recorded,  it  must  be  now  conceded  that  as, 
for  example,  terms  of  distinctions  have  been  applied  to  various 
forms  of  variola,  not  indicating  different  diseases,  but  only 
different  degrees  of  severit}^  so  also  the  so-called  diphtheria  of  a 
laryngitis  following  small-pox  is  not  a  separate  manifestation,  but 
only  a  natural  pathological  sequeaice  of  a  septic  inflammation  of  a 
mucous  membrane.      (See  Addendum,  p.  378.) 

I  am  not  able  to  agree  entirely  with  ^^Bosworth's  conclusions  in 
his  endeavour  to  divide  inflammatory  affections  of  the  upper  air- 
passages  by  sharp,  well-defined  lines,  into  catarrhal  inflammations 
and  those  characterized  by  fibrinous  exudations.  My  own  experi- 
ence especially  differs  from  his,  that  fibrinous  exudation  is  a  usual 
condition  of  ordinary  superficial  tonsillitis,  and  its  manifestation 
would  at  once  lead  me  to  suspect  a  septic  origin  of  an  attack.  I 
should  hold  that,  except  in  some  rare  cases  with  young  children, 
fibrinous  exudations  in  either  fauces  or  larynx  are  generall}^  sig- 
nificant of  microbic  influences.  Bosworth's  subdivision  of  these 
exudations  into  innocent  and  baneful  is  in  my  judgment  only  too 
likely  to  lend  encouragement  to  an  over-sanguine  prognosis. 

Why  some  affections  of  the  throat,  arising  apparently  from  the 


164 


DISEASES  OF  THE  THROAT  AND  NOSE. 


same  cause,  should  sometimes  attack  the  nares,  sometimes  the 
fauces,  and  sometimes  the  larynx,  is  a  problem  which  as  yet  is  by 
no  means  solved. 

By  far  the  majority  of  inflammations  of  the  larynx  are  of  a 
sub-acute  character,  and  arise  as  an  extension  from  the  nares 
or  fauces  in  association  with  nasal  stenosis.  Why  should  they 
not  by  preference  extend  into  the  oesophagus,  which  tube  is  much 
more  directly  continuous  with  the  pharynx?  ^^Cohen  says,  '  Most 
probably  because  the  flaccid  oesophagus  is  normally  closed  except 
during  the  act  of  deglutition,  and  thus  is  less  exposed  to  atmo- 
spheric influences  than  the  patulous  respiratory  tract.'  This 
answer  is,  however,  by  no  means  entirely  satisfactory,  for  we  see 
a  large  number  of  pharyngeal  diseases  of  more  or  less  pronounced 
atmospheric  origin,  and  having  a  direct  relation  to  the  digestive 
apparatus,  but  which  never  attack  the  larynx.  A  suggested  explana- 
tion is  based  on  the  steadily  growing  belief  in  the  parasitic  nature  of 
disease.  The  throat  affections  of  the  exanthemata  and  continued 
fevers,  as  also  diphtheria  and  almost  all  forms  of  insanitary  sore 
tliroat  and  probably  even  of  rheumatism,  commence,  as  a  rule,  in 
the  fauces  and  pharynx — rarely  if  ever,  be  it  noted,  in  the  nares, 
and  preferably  in  those  who  are  the  subjects  of  nasal  stenosis. 
It  is  probable  that  the  bacilli  respectively  characteristic  of  these 
conditions  are  both  swallowed  and  inhaled.  Those  swallowed 
may  be  checked  in  their  development  by  digestion ;  while  in  the 
case  of  those  inhaled,  absence  of  these  destructive  fluids  and 
the  free  access  of  oxygen  would  favour  the  activity  of  their  life- 
processes.  The  probability  of  the  explanation  I  have  here  offered, 
of  immunity  of  extension  of  pharyngeal  disease  to  the  oesophagus, 
is  strengthened  by  the  fact  that  while  tuberculous  ulceration  of  the 
pharynx  spreads,  as  a  rule,  downwards  to  the  larynx,  and  but  rarely 
upwards  from  that  region,  no  case  has  been  reported  of  extension 
from  the  fauces  to  the  gullet. 

We  have  spoken  of  catarrh,  and  it  will  be  well,  before  pro- 
ceeding further,  to  consider  what  is  meant  by  the  catarrhal 
tendency  ' — by  *  taking  cold  ' — the  condition  which  not  only 
predisposes  some  individuals  to  be  more  liable  than  others  to 
respiratory  affections  of  the  throat,  but  which  also  plays  so  large 
a  share  in  the  element  of  recurrence. 

Broadly  speaking,  the  words  imply  a  constitutional  condition 
either  original  or  acquired,  which  renders  the  individual  unable  to 
withstand  the  injurious  influences  of  a  lowered  temperature. 

^^Woakes,  applying  the  term  'modifications  of  nutrition  to  all 
the  processes  of  inflammation,  whether  acute  or  chronic,  as  well 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES,  165 


as  to  some  hypertrophies  of  tissue  which  are  either  congenital  or 
originate  shortly  after  birth,'  endeavours  to  account  for  them  all 
as  possessing  a  uniformity  of  type.  He  argues  that  all*  these 
'  modifications  of  nutrition  are  traceable  to  an  anatomical 
mechanism  normally  operating  in  the  healthy  economy,'  and  that 
this  anatomical  mechanism  is  to  be  *  found  in  that  portion  of  the 
nervous  system  constituted  by  the  ganglia  of  the  sympathetic  chain 
and  its  afferent  and  efferent  branches.'  In  other  words,  he  appears 
to  consider  all  forms  of  disease  of  the  throat,  nose,  and  ear,  from 
the  simplest  pharyngitis  to  diphtheria,  from  a  cold  in  the  head  to 
polypus  and  necrosing  ethmoiditis,  from  Eustachian  obstruction 
to  auditory  nerve  vertigo — as  dominated  by  vaso-motor  disturb- 
ance. The  arguments  by  which  this  view  is  supported  are 
plausible  and  elaborate,  but  in  truth  do  not  serve  us  very  much 
in  a  practical  sense  ;  for  so  far  from  directing  treatment,  as  one 
would  expect,  on  more  purely  medical  or  hygienic  lines  than  has 
hitherto  been  the  case,  probably  no  English  specialist  of  recent 
times  has  devised  bolder  surgical  operations  for  the  relief  of  these 
modifications  of  nutrition,  especially  in  the  naso-pharygeal  region, 
than  the  author  under  notice.  The  theory  is  withal  not  one  of 
entire  novelty,  except  in  the  extent  to  which  it  is  applied.  Carried 
to  its  logical  conclusion,  it  might  be  made  to  account  for  almost 
every  disease  to  which  mankind  is  subject.  Primarily,  without 
doubt,  the  vaso-motor  system  which  controls  the  circulation  is  at 
fault  in  the  majority  of  throat  diseases ;  but  the  catarrhal  ten- 
dency— the  disposition  to  take  cold — may  in  a  secondary  but  not 
less  important  sense  be  dependent  on  any  one  or  on  several  of  the 
many  and  varied  constituents  of  defective  assimilation  and  nutri- 
tion, and  the  practitioner  v/ill  require  to  make  careful  search  as 
to  the  individual  causes  of  a  baneful  nature  in  the  general  health 
of  each  separate  patient  as  he  comes  under  notice.  While,  there- 
fore, the  causation  of  the  so-called  catarrhal  condition  may  be 
largely  influenced  by  circulatory  defects  in  the  constitutional 
state,  sometimes  inherited  and  often  acquired,  there  is  nothing  to 
show  that  such  an  influence  has  any  more  power  over  passages  of 
the  throat  or  nose,  than  on  a  similar  condition  when  manifested 
in  the  common  bile-duct.  Moreover,  the  importance  of  the  many 
constitutional,  atmospheric,  and  functional  causes  for  inflammation 
of  the  air-passages  cannot  be  thus  ignored,  minimised  or  dis- 
missed. Macintyre  has  brought  forward  strong  evidence  to  sus- 
tain my  view  in  the  last  edition  (i8go),  that  so-called  catarrhal 
conditions  of  the  mouth  and  throat  are  intimately  related  to  the 
invasion  of  these  regions  by  micro-organisms. 


DISK  AS  ES  OF  THE  THROAT  AND  NOSE, 


In  connection  with  the  constitutional  conditions  influencing  the 
catarrhal  tendency,  we  may  here  conveniently  speak  of  other 
dyscrasise  predisposing  to  throat  diseases  scarcely  less  specific 
than  those  associated  with  tubercle  or  syphilis. 

The  constitutional  state  which  in  my  judgment  exercises  the 
strongest  influence  on  diseases  of  the  throat,  especially  of  the 
pharynx,  is  that  known  under  the  various  and  more  or  less  inter- 
changeable names  of  rheumatic,  gouto-rheumatic  or  gouty;  the 
darthous,  arthritic  or  lithic  acid  diathesis.  And  here  also  there  may 
be  traced  a  certain  relationship  between  the  systemic  cause  and 
the  local  result.  The  simple  rheumatic  throat,  consisting  of  pain, 
especially  in  performance  of  ordinary  muscular  acts,  with  but  little 
hyperaemia,  is  only  to  be  treated  by  local  measures  of  relief, 
supplementary  but  subordinate  to  those  required  of  a  more 
general  character ;  or,  to  look  at  the  matter  from  another  point  of 
view,  arrest  of  follicular  secretion  of  the  tonsils  leading  to  acute 
inflammation,  and  perhaps  suppuration,  will  occur,  under  etiolo- 
gical conditions  favourable  to  a  general  rheumatism,  and  will  be 
ushered  in  by  all  the  constitutional  signs  of  the  same  malad}-. 
Like  general  rheumatism,  no  sooner  is  one  side  of  the  throat 
relieved  than,  in  many  instances,  the  opposite  side  is  similarly 
attacked  ;  while  if  the  throat  affection  be  arrested  by  local 
measures  only,  a  sharp  attack  of  muscular  or  articular  rheu- 
matism may  ensue.  Again,  granular  pharyngitis,  a  lesion  of  the 
discrete  lymphoid  follicles  of  the  pharynx,  although  often  excited 
by  causes  of  functional  character,  generally  occurs  in  an  individual 
with  certain  well-recognised  faults  of  general  secretion  and  assim- 
ilation in  association  with  some  well-marked  diathesis  or  with 
'lasal  obstruction  On  these  accounts,  and  for  many  other 
reasons,  it  is,  in  my  opinion,  a  mistake  to  suppose  that  there  is  a 
special  individuality  of  pathology  of  diseases  of  the  throat  to 
anything  like  the  extent  that  we  find  in  the  case  of  the  eye  or 
ear. 

Second  only  to  the  darthous  diathesis  as  predisposing  factors 
in  throat  diseases  stand  the  various  exanthemata  and  other  fevers 
and  the  strumous  diathesis.  They  will  be  more  conveniently  dis- 
cussed, however,  under  various  headings  later. 

It  remains  to  be  noted  that  there  are  many  anatomical  facts  of 
a  surgical  character  apart  from  the  results  of  nasal  stenosis  which 
exercise  influences  of  a  special  nature  on  throat  diseases. 

Just  glancing  at  clefts  and  unduly  high  arches  of  the  palate  as 
troubles  purely  anatomical,  we  may  see  how  in  the  close  invest- 
ment of  the  mucous  lining  of  the  hard  palate  there  is  a  pre- 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DLSEASES.  \6; 

disposing  cause  to  disease  of  periosteum  and  bone  in  cases  of 
inflammation  and  ulceration  of  this  region,  and  on  account  of  its 
muscular  arrangement,  as  well  as  of  its  physiological  duties,  how 
important  is  health  of  the  soft  palate  to  all  the  functions  of  the 
upper  portion  of  the  throat. 

The  intimate  connection  of  the  faucial  tonsil  with  the  pharyngeal 
muscles  accounts  for  the  pain  in  deglutition  in  all  inflammations 
of  those  glands.  Enlargement  of  these  structures  as  a  cause  of 
deafness  is  not  due  to  closure  of  the  Eustachian  tube,  as  was  for- 
merly taught,  by  direct  pressure  of  the  enlarged  mass.  Such 
pressure  is  anatomically  impossible,  and  the  cause  is  to  be  found 
rather  in  extension  of  the  chronic  inflammation  and  thickening  of 
the  gland  to  the  tube,  and  by  disturbance  of  the  muscles  of  the 
soft  palate  connected  with  its  patency.  The  laxity  of  attachment 
of  the  pharynx,  so  necessary  to  its  mobility  and  contraction, 
accounts  for  the  disposition  to  effusion  and  suppuration  in  its 
surrounding  connective  tissues,  while  its  close  relationship  with  im- 
portant vessels  adds  very  specially  to  the  dangers  of  all  such  inflam- 
mations and  abscesses.  To  the  looseness  of  its  connections  may 
also  be  ascribed  much  of  the  liability  to  ulcerations,  to  the  forma- 
tion of  pouches  and  the  lodgment  of  foreign  bodies,  and  also  in  a 
measure  to  varices.  The  varieties  in  thickness  and  tension  of  the 
mucous  lining  and  submucous  coverings  of  the  larynx  account  for 
the  varying  liability  of  different  portions  to  congestion  and 
oedema. 

^^Treves  asserts  that  'the  affection  known  as  clergyman^s  sore 
throat  has  an  interesting  anatomical  basis,'  which  he  thus  explains  : 
'  The  mucous  membrane  of  the  larynx  is  well  provided  with 
mucous  glands,  whose  function  it  is  to  keep  moist  the  parts  con- 
cerned in  phonation.  When  an  individual  speaks  aloud  for  a  long 
while,  the  lining  of  the  larynx  tends  to  become  dry,  on  account  of 
the  large  amount  of  cold  air  that  is  drawn  directly  through  the 
mouth.  To  still  keep  these  parts  moist  the  mucous  glands  have 
to  exhibit  increased  energy  ;  and  in  those  who  speak  much  in 
public  the  glands  may  in  time  become  so  overworked  as  to  in- 
flame. It  is  the  inflammation  of  these  glands  that  constitutes  the 
present  affection.  The  glands  are  not  distributed  equally  over  all 
parts  of  the  larynx,  but  are  most  numerous  in  the  membrane 
covering  the  arytenoid  cartilages  and  parts  immediately  about 
them,  the  base  of  the  epiglottis,  and  the  interior  of  the  ventricle. 
It  is  in  these  parts,  therefore,  that  the  changes  in  chronic  glan- 
dular laryngitis,  or  dysphonia  clericorum,  are  most  marked.'  The 
statement  is  quoted  a.t  length  because  there  is  no  doubt  that  the 


DISEASES  OF  THE  THROAT  AND  NOSE. 


views  represent  the  prevaiiing  notions  as  to  the  pathology  of 
speaker's  and  teacher's  throat,  but  after  what  I  have  previously 
written,  it  must  be  evident  that  abeyance  of  nasal  respiratory 
function  from  obstruction,  the  associated  microbic  and  chemical 
contamination  of  the  oral  and  pharyngo-laryngeal  secretions,  and 
the  consequent  changes  in  the  lymph-secreting  mechanisms,  are 
factors  of  equal,  if  not  greater,  importance  than  lesions  of  the 
mucous  glands.  The  idea  that  simple  much-speaking,  indepen- 
dently of  faults  in  the  method  of  voice-production,  will  lead  to 
laryngeal  inflammation,  must  be  accepted  with  some  reserve  ;  for, 
as  it  is  hardly  necessary  to  remind  the  reader,  only  a  small  per- 
centage of  clergymen  and  other  active  voice-users  suffer  from  the 
disease. 

Of  very  great  importance  in  all  nervo-muscular  diseases  of  the 
larynx,  are  the  anatomical  relations  of  the  recurrent  laryngeal 
nerves,  already  described.  From  their  tortuous  course  and  their 
vicinity  to  vessels,  glands,  etc.,  it  is  easy  to  understand  that 
aneurisms  and  enlargement  of  glandular  structures  may  cause 
pressure  on  one  or  both  nerves,  and  thereby  give  rise  to  charac- 
teristic and  well-defined  symptoms  in  the  larynx,  to  be  con- 
sidered more  in  detail  in  the  section  devoted  to  laryngeal 
neuroses.  When  the  nerves  supplying  the  intrinsic  muscles  of 
the  larynx  are  injured,  vocalization  must  be,  and  respiration  may 
be,  impaired  ;  and  further  on  it  will  be  seen  how  numerous  are 
the  causes  which  may  affect  the  action  of  the  vocal  cords. 

Regarding  new  formations,  any  inflammatory  thickening  or 
loss  of  tissue  in,  or  new  growth  upon,  the  epiglottis  will  cause 
embarrassment  in  deglutition,  but  will  not  always  influence  the 
voice;  in  other  situations  a  similar  condition  will  aftect  phonation. 
It  is  astonishing  how  much  lateral  displacement  of  the  larynx, 
from  pressure  of  external  tumours,  may  take  place  without  embar- 
rassment of  either  voice,  deglutition,  or  respiration;  but  if  there 
be  the  slightest  constriction,  as  in  those  forms  of  goitre,  the  lateral 
lobes  of  which  embrace  and  compress  the  larynx  and  gullet, 
dyspnoea,  and  later  dysphagia,  become  prominent  and  distressing 
symptoms.  This  interesting  question  has  been  illustrated  by- 
various  specimens  exhibited  by  me  at  the  Pathological  Society 
(vols.  XXV.  and  xxvii.) ;  and  also  by  a  short  paper  entitled  '  On  the 
Causation  of  Dyspnoea  in  Suffocative  Bronchocele,'  which  appeared 
in  the  American  Journal  of  the  Medical  Sciences  for  April,  1877,  and 
which  was  suggested  by  perusal  of  a  graphic  report  of  a  case  of 
Suffocative  Bronchocele,  by  Dr.  John  B.  Roberts  of  Philadelphia, 
printed  in  the  same  journal  for  October,  1876. 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  109 

Foreign  bodies  are  sources  of  discomfort  in  all  parts  of  the 
throat.  Naturally,  if  the  situation  be  in  the  larynx,  respiration 
will  be  embarrassed;  but  even  when  one  is  impacted  in  the 
oesophagus,  it  is  liable  to  press  in  front  upon  the  trachea,  and  so 
give  rise  to  respiratory  symptoms.  When  the  oesophagus  is  the: 
seat  of  malignant  ulceration,  the  points  most  frequently  attacked 
are  (i)  opposite  the  cricoid  cartilage,  which  offers  the  only  point 
of  resistance  on  the  anterior  wall  of  the  oesophagus,  and  (2)  at 
its  entrance  into  the  stomach. 

Proceeding  now  to  consider  the  various  functions  of  the  throat 
in  their  etiological  relations  to  disease,  we  come  first  to  the 
physiological  duties  of  the  throat ;  and,  as  a  natural  consequence, 
a  large  proportion  of  throat  affections  exert  impeding  influences 
on  these  processes. 

Respiration. — One  of  the  main  predisposing  causes  of  respira- 
tory troubles  in  the  throat  is  an  unnatural  method  of  breathing 
through  the  open  mouth,  the  result  of  hypertrophic  morbid 
obstructions  in  the  nose,  in  consequence  of  which  the  air  is 
taken  directly  on  to  the  mucous  membrane  of  the  pharynx  and 
larynx,  unmodified  in  temperature,  unmoistened,  and  unfiltered  as 
it  would  be  if  breathed  through  the  natural  first  avenue  of  respira- 
tion— the  nostrils.  I  cannot  admit  with  ^^Gottstein  that  the  nasal 
cavity  '  imperfectly  fulfils  its  normal  function  in  this  direction,' 
for  any  defect  in  its  action  is  due  either  to  hypertrophy  and 
stenosis,  sometimes  to  a  pernicious  habit,  or,  it  may  be,  to  a 
pathological  process  brought  about  by  vices  of  civilization.  Long- 
continued  mouth-breathing  not  only  gives  rise  to  pharyngeal 
and  laryngeal  mischief,  but  it  also  intensifies,  if  it  does  not 
originate,  many  nasal  disorders.  It  is  perhaps  not  out  of  place 
to  suggest  here  that  Gottstein's  strong  advocacy  of  nasal  tampons 
indicates  a  want  of  appreciation  of,  or  at  least  of  respect  for,  the 
physiological  duties  of  the  nostrils.  Such  measures  would  appear 
to  be  far  more  calculated  to  cause  than  to  cure  nasal  disease. 
Another  respiratory  cause  of  throat  disease  to  be  frequently 
referred  to  in  these  pages  is  the  method  of  filhng  the  lungs  and  of 
economizing  its  exit  during  voice  use. 

Akin  to  the  function  of  respiration  is  the  influence  of  the 
general  circulation  on  throat  diseases,  independently  of  atmo- 
spheric or  other  influences  which  may  affect  it.  We  have  local 
congestions  and  inflammations  occurring  in  the  full-blooded  sub- 
ject, and  local  muscular  enfeeblements  in  the  anaemic.  We  find 
also  local  varices  associated  with  general  evidence  of  a  like  nature, 
such  as  rectal  haemorrhoids,  varicoceles,  varicose  veins  of  the 


I70 


DISEASES  OF  THE  THROAT  AND  NOSE. 


lower  limbs,  etc.,  and  with  similar  general  constitutional  symptoms, 
or  caused  by  constitutional  states  of  functional  local  strains  of  the 
same  nature  as  produce  the  like  effects  elsewhere.  Comparatively 
slight  deficiency  of  general  vaso-motor  control  will  cause  conges- 
tion of  the  thyroid  gland  and  of  the  mucous  membrane  of  the 
larynx,  with  a  possible  accompaniment  of  varix  of  the  pharynx 
and  the  base  of  the  tongue,  and  of  hypertrophy  of  the  lingual 
tonsil.  One  or  all  of  these  conditions,  though  often  unrecognised, 
generally  exist  together  with  lymphoid  hypertrophies,  as  objective 
factors  in  the  production  of  the  condition  known  as  globus 
hystericus,  a  term  which  represents  one  of  the  many  symptoms  1 
am  now  in  the  habit  of  generically  describing  as  pharyngeal 
tcnesimis.  In  point  of  fact  the  phantom  hysteria  need  not  be,  and 
seldom  is,  guilty  of  these  sensations,  and  as  applied  to  throat 
diseases  the  term  is  a  distinct  misnomer  if  it  is  intended  to 
indicate  that  pharyngeal  tenesmus  constitutes  a  series  of  symptoms 
which  are  purely  subjective  in  character  and  in  no  degree  de- 
pendent, as  I  contend,  on  objective  and  material  causes.  The 
influence  of  disorders  of  the  menstrual  function  on  the  respiratory 
passages  are  so  well  marked,  as  in  ozaena  and  some  so-called 
hysterical  throat  symptoms,  that  we  are  often  led  at  once  to 
make  pertinent  inquiry  on  such  points  merely  from  the  local 
evidence,  and  with  the  result  of  much  wider  applied  and  more 
complete  therapeutic  measures. 

Diseases  of  the  throat  in  relation  to  the  function  of  deglutition 
are  often  due  to  disobedience  of  physiological  laws  in  performance 
of  the  act  of  mastication.  Deficient  natural  teeth,  or  imperfect 
action  of  artificial  substitutes,  give  rise  to  many  functional  dis- 
orders of  swallowing,  and  may  even  be  the  precursor  of  organic 
lesions.  Local  irritation  of  food  unduty  hot  in  temperature,  of 
piquant  in  character,  will  lead  to  undue  capillary  stimulation,  and 
reactionary  relaxation  and  congestion.  The  frequent  taking  o. 
ices  and  iced  water  is  doubtless  also  a  source  of  many  throat 
disorders,  but  not,  in  my  experience,  to  anything  like  the  extent 
caused  by  the  contrary  practice.  In  either  case  the  mode  of  action 
on  the  laryngeal  mucous  membrane  is  similar  to  that  of  sudden 
alternations  in  the  temperature  of  the  inspired  air.  Alcoholic 
drinks  exert,  for  the  most  part,  except  in  their  more  ardent  forms, 
a  local  influence  on  the  throat  mainly  through  the  general  system. 
But  there  are  so  many  specially  characteristic  symptoms  and  effects- 
produced  from  this  cause  that  there  can  be  no  doubt  as  to  the 
directly  deleterious  action  of  stimulants  on  the  organs  of  the  voice. 

I  have  reserved  for  the  last  of  functional  abuses  as  causes  of 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  171 


throat  disorder  that  of  defective  voice-production,  though  of  its 
importance  I  hold  very  strong  views,  probably  stronger  than  those 
generally  taught  or  accepted.    -'^Mandl  was  the  first  to  point  out 
that  fatigue  of  the  voice  is  a  direct  result  of  a  wrong  process 
of  use,  and  having  for  many  years  been  convinced  of  the  truth  of 
his  teaching,  I  have  lost  no  opportunity  of  enforcing  it,  both  in 
treatises  and  pamphlets  and  delivered  lectures.    I  go  even  further 
than  Mandl,  and  believe  that  the  generally  accepted  doctrine  of  a 
special  proclivity  of  singers  to  throat  troubles  lies  entirely  in  vices 
or  imperfections  of  cultivation.   -^Carl  Seiler,  as  the  son  of  a  most 
distinguished  author  and  teacher,  has  naturally  grasped  the  fact, 
and  his  explanation  of  the  causes  of  granular  pharjmgitis  is  so 
complete  in  this  direction  that  it  should  be  laid  to  heart  by  all 
teachers  of  singing,  as  well  as  physicians.    I  am  not  able  entirely 
to  agree  with  either  Seiler,  Cohen,  or  others  who  think  that  any 
portion  of  the  larynx,  much  less  the  vocal  cords  themselves,  is 
often  over-strained  '  in  singing,  screaming,  public  speaking,  pro- 
longed reading,  talking  to  the  deaf,  quarrelHng,  and  so  on for 
not  only  have  I  rarely  found  local  evidences  of  such  a  condition, 
or  local  treatment  of  the  larynx  of  avail  in  its  cure,  but,  on  the 
other  hand,  I  have  seldom  failed  to  find  the  cause  of  the  vocal  lesion 
in  the  nose  or  pharynx,  nor  to  effect  a  cure  by  surgical  treatment 
of  those  regions,  supplemented  by  educational  correction  of  a  func- 
tional fault  in  production.    And  I  am  here  tempted  to  make  two 
digressions,  one  as  to  the  value  of  knowledge  gained  by  the  laryngo- 
scope as  an  aid  to  the  attainment  of  greater  perfection  of  the  vocal 
arts  and  by  consequence  as  a  safeguard  against  functional  diseases 
on  the  part  of  its  exponents  ;  and  secondly  on  the  question  of  rest 
per  se  as  a  curative  agent.    As  to  the  first,  it  is  very  unfortunate 
that  great  singers,  whose  perfection  is  to  a  large  extent  the  gift  of 
nature,  should,  because  they  have  not  felt  the  necessity  of  phy- 
siological teaching,  ignore  its  value  to  the  less  highly  gifted ;  and 
it  is  especially  to  be  regretted  that  at  least  one  throat  specialist — 
a  highly  respected  American  confrere — who  has  the  reputation 
of  being  also  a  fine  singer,  should  give  support  and  weight  to 
the  screechings  of  the  uninitiated  against  the  capability  of  the 
laryngoscope  to  help  in  formulating  methods  of  voice-produc- 
tion ;  and  the  rather  that  his  recognition  of  the  more  prominent 
causes  of  vocal  disability  is  evidently  founded  on  much  laryngo- 
scopic  experience.    Such  objectors  particularly  forget  that  the 
laryngoscope  was  the  invention,  not  of  a  physician,  but  of  a  pro- 
fessor of  singing — Manuel  Garcia — and  was  the  direct  outcome  cf 
his  endeavours  to  settle  certain  disputed  points  on  tone-production 


172 


DISEASES  OF  THE  THROAT  AND  NOSE. 


in  the  brynx.  The  investigations  of  that  famous  teacher  have 
not  onty  had  that  effect,  but  they  have  led  to  the  formulation  of 
certain  laws  in  teaching  which  were  previously  promulgated  only 
as  ideas  unsupported  by  facts.  My  views  on  the  importance  of 
scientific  teaching  as  a  foundation  of  good  singing  have  been 
enforced  with  particular  detail  in  a  lecture,- to  which  those  in- 
terested may  be  referred ;  and  also  in  Voice,  So7tg,  and  Speech. 
I  must  limit  further  present  reference  to  the  subject  to  enumera- 
tion of  only  a  few  instances  of  the  value  of  laryngoscopic  teaching. 
It  may  be  noted  that  (i)  the  laryngeal  mirror  proves  the  absurdity 
of  supposing  that  the  ventricular  bands  approach  in  tone-produc- 
tion— a  supposition  on  which  a  very  pernicious  school  of  teaching 
is  founded ;  (2)  by  the  same  means  may  be  demonstrated  the 
various  methods  of  commencing  and  of  ending  a  tone;  (3)  a 
pupil  may  be  shown,  and  therefore  be  better  enabled  to  appre- 
ciate, the  various  positions  of  the  cords  and  the  shape  of  the 
space  between  them  in  production  of  the  different  registers ;  and 
(4)  the  effects  of  forcing  the  registers  beyond  their  natural  limit 
may  be  similarly  demonstrated.  And  akin  to  these  lessons  in 
the  larynx,  physiological  demonstration  of  the  action  of  the  soft 
palate  in  tone-production  enables  the  pupil  to  appreciate  the 
importance  of  exercises  directed  to  the  strengthening  of  the 
muscles  in  this  region  with  increased  readiness  and  thoroughness. 

The  subject  of  rest  as  a  curative  agent  may  appear  out  of  place  in 
a  chapter  on  causes  of  throat  affections  ;  but  as  I  have  shown  how 
important  it  is  to  recognise  faults  in  method  as  etiological  factors 
of  disease,  1  would  here  incidentally  express  my  equally  strong 
conviction  that,  while  rest  may  obviate  functional  difficulty  for  so 
long  as  it  is  observed,  it  does  not  prevent  speedy  relapse  of  a 
trouble  due  to  wrong  production  so  soon  as  functional  activity  is 
resumed,  provided  the  fault  of  method  remains  uncorrected.  It 
is  in  the  want  of  recognition  of  this  fact  that  an  explanation  will 
often  be  found  for  the  frequency  of  recurrence  of  the  majority  of 
the  vocal  disabilities  of  singers,  for  it  is  an  undoubted  fact  that 
the  best  singers,  and  the  greatest  orators — those  who  most  use 
the  voice — enjoy  the  greatest  immunity  from  functional  disability, 
and  this  because,  though  they  exercise  the  organ  largely,  they 
exercise  it  rightly,  and,  therefore,  without  evil  consequence. 

It  remains  only  to  touch  on  a  few  etiological  factors  of  throat 
disease  of  a  hygienic  character.  Omitting  those  of  age,  sex, 
aeredity,  etc.,  which  have  no  special  signification  in  this  connec- 
tion, we  may  consider  those  of  climate  or  atmosphere,  occupation, 
surroundings,  and  clothing.    Some  dietary  faults  leading  to  throat 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  173 


affections  have  been  alluded  to  under  the  functional  portion  of  our 
remarks. 

Concerning  atmosphere  and  climate,  -^]ohn  N.  Mackenzie,  has 
in  a  recent  article  (brought  under  my  notice  since  this  chapter 
was  first  prepared)  treated,  with  much  originality  and  vigour,  on 
the  *  geographical  limits  of  catarrhs,'  and  has  laid  down  certain 
propositions,  with  most  of  which  I  can  but  express  complete 
concurrence.  He  says  :  *  In  those  countries  where  extremes  of 
temperature  follow  each  other  in  rapid  succession,  where  the 
thermo-  and  barometrical  fluctuations  are  most  sudden,  and 
occur  with  the  greatest  frequency,  and  where  the  material  com- 
position of  the  atmosphere  is  continually  changing,  catarrhal 
affections  of  the  naso-laryngeal  tract  are  most  frequently  met 
with.  The  appearance  of  the  disease  seems  to  depend  not  so 
much  upon  the  degree  of  heat  or  cold  as  upon  the  rapidity  and 
intensity  of  the  change  from  one  to  the  other.'  In  this  way  is 
explained  the  origin  of  severe  catarrhs  in  warm  weather,  on 
occurrence  of  cooling  showers,  or  from  the  influence  of  cold, 
damp  nights  in  tropical  climates.  The  influence  of  season  is  also 
explained  ;  for  '  while  spring  and  autumn  furnish  perhaps  the 
largest  percentage  of  nasal  and  laryngeal  catarrhs,  the  coryza 
which  appears  in  the  summer  months,  when  the  air  is  suddenly 
cooled  or  altered  by  electrical  and  other  disturbances,  yields  to 
none  in  the  severity  of  its  symptoms  and  course.'  I  entirely 
concur  with  the  same  author's  statement  that  the  injurious  effect 
of  cold  per  se  has  been  grossly  exaggerated ;  whereas  excessive 
moisture — i.e.,  damp — exercises  a  potent  influence  in  production 
of  catarrhal  inflammations,  and  is  almost  equally  intensified  for 
evil  by  oppressive  heat  as  by  extreme  cold. 

That  the  inspiration  of  cold  dry  air  is  not  harmful  (except  on 
sudden  change  from  heat),  but,  on  the  contrary,  beneficial,  we 
now  know  by  manifold  experience  of  the  treatment  of  phthisis  by 
residence  on  snow-covered  mountain  plateaux  ;  but  it  is  difterent 
when  we  consider  dry  cold  air  as  it  may  strike  the  larynx  or  its 
neighbourhood  externally,  either  as  a  draught  on  an  overheated 
body,  or  by  exposure  to  keen  north  or  north-east  winds.  From 
such  a  cause  acute  inflammation,  with  deficient  mucous  secretion 
and  with  marked  spasm,  may  occur.  The  only  apparent  cause,  in 
some  cases  of  abductor  paralysis,  is  of  such  a  nature.  It  is  doubt- 
ful if  hot  winds,  unaccompanied  by  moisture,  act  as  factors  in  the 
causation  of  throat  diseases.  I  have  not  sufficient  clinical  evidence 
to  make  any  assertion  on  the  subject,  but  I  am  inclined  to  think 
that  while  keen  draughts  of  cold  air  acting  on  an  overheated  and 
fatigued  individual  may  predispose  to  submucous  forms  of  inflam- 


174 


DISEASES  OF  THE  THROAT  AND  NOSE. 


mation  (oedema),  inspiration  of  damp  cold  air,  wet  clothinof,  etc., 
are  the  main  etiological  factors  of  mucous  infammations.  An- 
alogies for  this  view  may  be  found  in  the  relative  causes  of  a 
pneumonia  and  a  bronchitis. 

Just  touching  on  the  question  of  soil,  and  noting,  for 
instance,  the  difference  of  liability  to  throat  affections  of  those 
who  reside  on  clay  as  contrasted  with  the  comparative  immunity 
of  inhabitants  on  gravel,  we  next  come  to  dust  as  a  cause  of  naso- 
pharyngeal and  laryngeal  disease.  I  am  here  unable  to  express 
agreement  with  John  Mackenzie  that  *  comparatively  few  cases  of 
inflammation  originate  in  this  way ;'  for  I  have  seen  many  in- 
stances in  which  the  dust  of  a  ball-room,  of  the  country,  or  of  the 
street,  will  be  the  direct,  constant,  and  apparently  the  sole  cause 
of  an  attack.  A  gentleman  at  the  present  time  (1887)  is  under  my 
care  who  suffers  from  severe  coryza,  with  symptoms  of  pseudo  hay- 
fever  and  asthma,  from  dust,  however  inhaled — as,  for  instance,  in 
the  course  of  a  ride  on  horseback.  This  patient  also  finds  the  dust 
arising  from  wood  pavement — in  which  much  insanitary  material 
is,  as  it  were,  ground-in,  to  become  separated  in  dry  weather — 
peculiarly  provocative  of  attacks  ;  and  this  is  by  no  means  a 
solitary  case.  That  the  dust  is  the  exciting  cause  is  proved  by  the 
fact  that  in  many  instances  immunity  against  its  influence  may  be 
ensured  by  the  simple  measure  of  anointing  the  inside  of  the 
nostrils  with  vaseline.  And  this  leads  me  to  say  that  I  believe  it 
will  generally  be  found  that  the  predisposing  cause  in  all  cases 
of  inflammation  excited  by  dust — and,  indeed,  of  many  other 
varieties — is  an  unduly  hyperaemic  and  hyperaesthetic  condition  of 
the  coverings  of  the  middle  and  inferior  turbinated  bones.  This 
subject  will  receive  further  discussion  later. 

Aflied  to  this  question  of  dust  are  the  injurious  results,  fre- 
quently witnessed,  of  the  breathing  of  insanitary  germ-laden  atmo- 
spheres, due  either  to  unhealthy  surroundings  or  imperfect  venti- 
lation, and  again  the  overcharging  of  the  atmosphere  with  volatile 
matter  of  a  poisonous  nature — as  in  certain  chemical  and  other 
manufactures,  and  especially  in  rooms  filled  with  tobacco  smoke. 
-^I  have  elsewhere  treated  at  such  length  of  the  use  of  tobacco  as  a 
frequent  cause  of  throat  disorder  in  singers,  and  in  a  less  degree 
in  all  brought  under  its  sway,  that  I  will  content  myself  here 
with  saying  that  there  is  little  reason  to  doubt  that  the  inhalation 
of  an  atmosphere  charged  with  tobacco  smoke  is  far  more  banclul 
in  its  local  effects  than  the  moderate  habit  of  smoking  in  the 
open  air  or  in  well-ventilated  apartments.  The  explanation  of  this 
fact     so  obvious  as  not  to  require  more  detafled  consideration. 


ETIOLOGY  AND  PATHOLOGY  OF  THROAT  DISEASES.  175 

Finally,  allusion  should  not  be  omitted  to  the  gradually  accu- 
mulating and  convincing  evidence  of  the  promulgation  of  disease, 
especially  of  tubercle,  by  the  contagion  of  germs  inspired  through 
the  air-passages. 

In  the  matter  of  clothing,  insufficiency  of  covering  and  reten- 
tion of  damp  garments  are  more  liable  to  induce  throat  diseases 
than  too  much  clothing,  unless,  in  the  latter  case,  the  patient  is 
careless  to  regulate  the  amount  according  to  changes  of  tempera- 
ture to  which  he  may  be  subjected.  Russians  and  Canadians, 
who  wear  the  warmest  furs  out  of  doors,  but  instantly  remove 
them  on  entering  a  dwelling-house,  are  less  liable  to  throat  dis- 
eases than  the  English,  who  sit  through  a  two  hours'  service  in 
church  in  overcoat  and  other  extra  outdoor  coverings ;  or  who, 
on  fhe  other  hand,  will  stand  at  an  open  grave  on  damp  clay  per- 
meated with  exhalations  from  decaying  matter,  and  with  head 
uncovered,  quite  irrespective  of  the  wind  or  weather.  As  a  con- 
verse of  the  proverb  regarding  one  marriage  leading  to  others, 
attention  to  the  much  more  serious  truth  that  many  deaths  arise 
directly  from  disease  engendered  by  funeral  attendance  at  the 
grave-side  should  be  more  generally  urged  on  the  public ;  and  this 
fact  should  be  one  strong  argument  added  to  the  many  others  in 
favour  of  cremation. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

TITLE  OF  WORK  REFERRED    1 0. 

I 

Cohen. 

0/>.  ClL,  p.  I. 

156 

2 

Bloch. 

^Pathology  and  Therapeuiics  of  Moiit/i- 

y    Breathing.     Wie'sbaden,  1889. 

3 

Kingston  Fox. 

\Journ.  of  Anat.  and  Physiol.,  vx)l.  xx.. 
\    P-  559- 

Hill. 

4 

Brit.  Med.Joiirn.  Sept.  I  and  15,  18SS. 
f  Pouc/iefs  Journ.  d'' Anatoniie.  Pal•i^, 
I  1888. 

f  1  onsillitis      iji      Rheumatic  States. 
\    London,  1889. 

157 

5 

Retterer. 

158 

Hill. 

Miller. 

ijourjial  of  Laiytigology,  vol.  v.  Sept., 
\     1891.    Report  of  Seventh  luteruat. 
\     Congress  of  Hygiene  and  De/noi;rap/iy. 

7 

8 

Macintyre. 

\ Journal  of  Laryngology,  vol.  \.  May 
and  June,  1891.    Pp.  173  and  221. 

161 

9 

Cunningham. 

il  Report  of  Seventh  Internal.  Congress  Q'f 
\     Hygiene  and  Demography. 

161 

10 

ROUX  AND  YeRSIN. 

/ Annates  de  V histitiU  Pasteur.  \\\x\ 
\  1888. 

162 

II 

Klein. 

Micro-organisms  and  Disease.  1890. 

[Art.    Maladies   de   la   Bouche    et  du 
\     Pharynx.  Traite  de  Medicine,  Paris, 
t  1892. 

162 

12 

RUAULT. 

163 

13 

Thorne-Thorne. 

Brit.  Med.  fourn.    Feb.,  1891,  p.  457. 

163 

GOTTSTEIN. 

{  Diseases  of  the  Larynx.    English  trans- 

14 

-     lation,  by  Dr.  McBride,  p.  224,  etc. 
1     Edinburgh,  1885. 

DISEASES  OE  THE  THROAT  AND  NOSE, 
REFERENCES  TO  AUTHORITIES. 


NO. 


TITLE  OF  WORK  REFERRED  TO 


164 

15 

BOSWOR  i  II. 

164 

16 

Cohen. 

164 

17 

WOAKES. 

167 

18 

Treves. 

169 

19 

Gottstein. 

171 

20 

Mandl. 

171 

21 

Carl  Seiler. 

172 

22 

Lennox  Browne. 

173 

23 

John  N.  Mackenzie 

174 

24 

Lennox  Browne. 

!  j  J  raits.  Ajnerican  Laryngological  Asso- 
I  \_    ciation,  p.  4.    New  York,  1884. 
Op.  ciL,  p.  5. 

Post- Nasal  Catarrh,  etc.  London,  1884. 
j Surgical  Applied  Anatomy,  p.  132, 
\^    London,  1884. 

Op.  cit.,  p.  141. 

Hygiene  de  la  Voix.    Paris,  1876. 

{Handbook  of  Diseases  of  Throat,  etc., 
2nd  edition,  p.  177  et  seq.  Philadel- 
phia, 1883. 
Sconce  end  Singing.    London,  1884. 

{yEtiology  of  Inflammation  of  the  Air- 
Passages.   Irans.  of  American  Laryn- 
gological  Association,  1886. 
(Voice- Use  and  Stiiuulants.  Londori, 

L  1885. 


CHAPTER  IX. 


DISEASES  OF  THE  PHARYNX. 

Note.— References  to  the  coloured  illustrations  at  the  end  of  the  volume  are  made 
thus  :  (Fig.  12,  Plate  II.) ;  to  engravings  in  the  text,  thus  :  (Fig.  CIL). 

Disease  of  the  pharynx  and  fauces  affects  primarily  the  function 
of  deglutition.  If  the  isthmus  of  the  fauces  be  narrowed,  or  if 
the  antcro-posterior  space  of  the  lower  pharynx  be  diminished  by 
abscess  or  new  growth,  pharyngeal  respiration  will  be  interfered 
with,  and  if  the  naso-pharynx  be  involved,  nasal  respiration  will 
also  be  impeded,  and  the  senses  of  hearing,  taste,  and  smell  will 
be  more  or  less  impaired.  Resonance  and  timbre  of  voice  are 
altered  by  pharyngeal  disease,  as  also  is  speech  (articulation),  but 
the  pitch  is  not  necessarily  affected. 

The  most  common  morbid  affections  of  the  throat  which  come 
under  the  category  of  pharyngeal  disease  are  those  which  are  in- 
flammatory in  their  origin,  and  these  usually  attack  the  pharynx  as  a 
whole  ;  but  it  often  happens,  as  ^  Cohen  has  pointed  out,  that  there 
exist  *  certain  territorial  regions,  which,  in  consequence  of  participa- 
tion in  the  same  vascular,  lymphatic  or  nervous  distribution,  are  apt 
to  become  sore  or  inflamed  together.  Thus  the  anterior  surface, 
of  the  palate  and  uvula,  the  anterior  folds  of  the  palate,  the  tonsfls,, 
and  sometimes  the  base  of  the  tongue,  form  one  region  ;  the  pos-. 
terior  palatine  folds,  posterior  surface  of  the  palate,  upper  portion, 
and  vault  of  the  pharynx,  and  posterior  portion  of  the  nasal  fossaS: 
form  another  ;  the  lower  pharynx,  epiglottis,  lingual  sinuses,  and 
upper  portion  of  the  larynx  form  a  third.'  It  is  principally  to, 
diseases  in  the  first,  and  with  a  portion  of  the  second,  of  these; 
somewhat  arbitrarily  subdivided  territories  that  our  attention  willj 
be  at  present  directed  ;  that  is  to  say,  with 

THE  ORO-PHARYNX  AND  FAUCES. 

These,  as  explained  in  the  section  on  Anatomy,  comprise  that 
part  of  the  throat  which  may  be  seen  ai  the  back  of  the  mouth  by 
direct  or  reflected  light,  without  the  intervention  of  mirrors  for 

12 


173 


DISEASES  OF  THE  THROAT  AND  NOSE, 


exploration  of  the  upper — naso-pharyngeal — or  lower — laryngo- 
pharyngeal— region  ;  or,  to  speak  still  more  definitely,  our  first  group 
will  include — 

of  the  Anterior  and  Posterior  Palatine  Folds. 
„    Posterior  Wall  of  the  Oro-Pharynx. 
„    Base  of  the  Tongue. 

Soft  Palate  and  Uvula, 
„  Tonsils. 

The  oro-pharynx  and  fauces  are  liable  to  inflammations  which 
may  be  acute  or  chronic,  forming  the  affection  popularly  known 
as  *  Sore  Throat.'  Such  inflammation  may  be  general,  and  in- 
volve all  the  tissues ;  or,  more  commonly,  as  already  mentioned, 
only  portions  of  the  various  parts  which  combine  to  form  the 
upper  throat. 

Inflammations  of  the  pharynx,  when  primary,  are  usually  called 
*  catarrhal ;'  though  diathetic  influences,  to  be  scarcely  considered 
secondary,  as  those  of  rheumatism  and  scrofula,  as  w^ell  as  func- 
tional abuses,  frequently  play  an  important  part  in  the  origin  and 
course  of  the  disease  broadly — that  is  to  say  loosely — denominated 
catarrhal  pharyngitis. 

I  agree  with  ^Schech  in  not  recognising  a  purely  gouty  sore 
throat,  although  I  have  seen  cases  in  which  administration  of 
gouty  specifics  were  necessary  adjuncts  to  the  local  measures 
taken  for  relief.  Nor  do  I  consider  it  necessary  to  speak  of  a 
rheumatic  angina  as  a  separate  malady,  thoroughly  convinced 
though  I  am  of  the  very  frequent  influence  of  such  a  diathesis. 
I  have,  for  example,  often  seen  cases  of  pharyngitis,  subacute  in 
intensity,  and  characterized  by  undue  hyperaemia,  and  great  irri- 
tabilit}^  of  the  mucous  membrane  ;  and  they  have  also  been 
associated  with  eczema,  especially  of  the  auricle,  of  the  gouto- 
rheumatic  nature  of  which  there  is,  of  course,  but  little  difference 
of  opinion.  To  further  simplify  the  subject,  I  do  not  devote  any 
space  to  herpes  of  the  pharynx,  because  it  is  an  extremely  rare 
disease  in  this  country.  In  the  very  few  cases  I  have  seen,  the 
herpetic  eruption  has  been  manifested  on  the  anterior  portion  of 
the  soft  palate.  Occasionally,  also,  I  have  witnessed  an  aphthous 
exudation  in  the  pharynx  of  the  adult,  unaccompanied  by 
stomatitis.  The  patients  have,  for  the  most  part,  been  females. 
^Schech  mentions  also  a  pharyngitis  following  scurvy,  and  gives 
to  it  the  name  of  angina  scorbutica.  Neither  of  these  appear  to 
•me  to  require  separate  consideration. 

.    More  legitimate  secondary  forms  of  pharyngeal  inflammation 


Diseases 

»» 


ACUTE  PHARYNGITIS. 


1/9 


are  those  arising  in  the  course  of  the  continued  fevers  and  ex- 
anthemata, those  due  to  the  toxic  influence  of  impure  water  and 
defects  of  drainage,  and  the  special  manifestations  which  are 
-exhibited  in  this  region  in  connection  with  syphihs,  cancer,  and 
tuberculosis. 

ACUTE   PHARYNGITIS,   CYNANCHE   PHARYNGEA,  ANGINA 
SIMPLEX  VEL  CATARRHALIS  (Fig.  12,  Plate  II.). 

The  grades  of  pharyngitis  may  vary  from  a  simple  hypersemia 
or  erythema  with  slight  submucous  infiltration,  to  an  acute 
phlegmonous  inflammation  with  oedema,  fibrinous  exudation,  or 
suppuration,  such  modifications  depending  largely  on  the  nature 
of  the  etiological  factor.  The  milder  forms  are  generally  due  to 
■cold  or  chin,  and  for  the  most  part  exhibit  but  local  symptoms  of 
no  particular  gravity  ;  the  second  have  a  diathetic  or  septic  origin, 
■and  exerting  a  wider  and  more  serious  influence  on  the  general 
economy,  call  more  urgently  for  constitutional  as  well  as  local 
treatment.  All  varieties  are  associated  with  more  or  less  nasal 
obstruction. 

Etiology. — Age  exerts,  in  my  experience,  but  a  very  indefinite 
influence  on  catarrhal  pharyngitis,  though  common  sore  throat  is 
said  to  be  most  frequent  in  children  and  youths.  When  such  is 
the  case,  a  scrofulous  diathesis  is  generally  at  the  root  of  the 
trouble  ;  while  in  the  adult  the  constitutional  tendency  is  most 
frequently  rheumatic,  this  being  evidenced  in  varying  degrees  m 
different  individuals.  In  all,  poor  food,  insufficient  clothing,  bad 
ventilation,  and  any  circumstance  likely  to  vitiate  the  general 
circulation  are  amongst  prominent  predisponents.  In  the  adult, 
occupations  of  a  sedentary  character,  as  well  as  those  involving 
respiration  in  poisonous  atmospheres  ;  alcoholic  intemperance, 
the  use  of  tobacco,  over-indulgence  in  highly-seasoned  dishes,  and 
the  taking  of  hot  fluids,  are  factors  to  be  sought  for,  and  when 
present,  corrected,  since  they  all  act  as  local,  and  many  of  them 
as  general  predisponents. 

Amongst  the  most  usual  exciting  causes  is  that  of  a  'cold.' 
Occupation  of  a  sedentary  character,  in  which  the  subject  takes 
insuflicient  exercise  for  the  well-being  of  his  general  circulation, 
has  been  mentioned  as  a  predisponent ;  but  it  is  probable  that  in 
such  a  case  the  subject  has  carried  on  his  employment  in  an  in- 
sufficiently ventilated  room,  for  I  find  pharyngitis  equally  common 
amongst  tailors  who  sit,  and  in  printers  who  for  the  most  part 
stand,  to  their  work,  the  atmospheric  conditions  being  equally 
pernicious  in  both  cases.  In  these  and  many  other  trades  the 
•exciting  cause  is  generally  a  *  chill,'  mainly  brought  about  by 


DISEASES  OF  THE  THROAT  AND  NOSE. 


exposure  to  draughts  of  cold  air  striking  on  an  overheated  body. 
The  disease  is  thus  common  in  people  engaged  near  hot  furnaces, 
or  in  those  who,  working  in  ill-ventilated  and  over-crowded 
rooms,  are  exposed  to  draughts,  or  who  go  out  of  such  rooms  into 
a  suddenly  changed  atmosphere.  Damp-cold  air  is  particularly 
likely  to  cause  inflammation  of  the  throat ;  hence  the  larger  pro- 
portion of  such  cases  occur  in  the  spring  and  autumn,  or  on  the 
occurrence  of  a  thaw  after  hard  frosty  weather.  Use  of  the  voice 
under  unfavourable  conditions  may  lead  to  pharyngitis,  whether 
followed  or  not  by  inflammation  of  the  larynx.  Amongst  trau- 
matic causes  of  pharyngitis  may  be  named  irritant  poisons,  boiling 
water,  and  scorching  heat  of  steam  or  flame,  and  the  lodgment  of 
foreign  bodies,  as  the  small  bones  of  fish,  game,  etc. 

Children  are  very  liable  to  simple  catarrhal  sore  throat,  the  local 
tendency  passing  off  as  they  grow  up,  though  too  frequently  the 
predisposition  is  perpetuated  in  a  liability  to  more  serious  catarrhal 
disorders,  which  perniciously  influence  the  whole  period  of  life. 

As  previously  pointed  out  (Chap.  VIII.),  a  large  number  of 
cases  of  pharyngitis  are  met  with  in  the  victims  of  nasal  and  naso- 
pharyngeal obstruction,  and  this  is  especially  noticeable  in  the 
case  of  the  young. 

Symptoms  :  A.  Functional. — The  voice  is  thick  and  husky  in 
enunciation,  but  there  is  rarely  actual  vocal  hoarseness  or 
aphonia  unless  the  disease  extend  to  the  larynx.  The  voice  is 
quickly  fatigued,  and  exercise  thereof  is  not  infrequently  painful. 

Respiration. — Unless  associated  with  laryngitis  there  is  no^ 
dyspnoea,  but  nasal  respiration  is  often  obstructed. 

Cough. — True  cough  is  seldom  present,  but  there  is  usually  a. 
constant  tendency  to  hawk  or  hcmf  accompanied  by  slight  expec- 
toration of  viscid,  transparent,  more  or  less  greyish  pellets  of 
mucus,  which  are  occasionally  streaked  with  blood. 

Deglutition. — The  act  of  swallowing  is  always  painful,  or  at 
least  accomplished  with  discomfort  in  the  acute  form. 

Hearing  is  usually  impaired  in  those  cases  where  there  is- 
enlargement  of  faucial,  pharyngeal  or  tubal  tonsils,  or  even  in 
inflammation  of  the  posterior  pillars  of  the  fauces. 

The  Senses  of  Taste  and  of  Smell  may  be  both  temporarily 
impaired. 

Pain,  independently  of  exercise  of  functional  action,  is  a 
strongly-marked  symptom  of  pharyngeal  inflammation.  There  is 
very  generally  first  described,  a  feeling  of  stifl'ness,  with  itching ; 
then  stinging  or  shooting,  followed  by  a  sensation  as  of  great 
tightness  and  constriction,  and  of  the  constant  presence  of  a 
foreign  body  in  the  throat,  causing  the  patient  to  repeatedly  per- 
form the  act  of  swallowing.    Pain  in  the  tympanum  is  either  the. 


ACUTE  PHARYNGITIS, 


l8t 


result  of  Eustachian  catarrh  and  obstruction,  or  it  is  conveyed  from 
the  throat  along  the  main  trunk  of  the  glosso-pharyngeal  to  Jacob- 
son's  nerve.  When  pharyngitis  extends  to  the'  laryngo-pharynx, 
■every  movement  of  the  larynx,  or  even  of  the  neck,  may  be 
attended  with  distress. 

B.  Physical. — Colour  is  increased  according  to  the  severity  of 
the  attack,  from  a  simple  bright  pink  to  a  livid  scarlet,  and  with 
exaggeration  of  the  calibre  and  distinctness  of  the  superficial  capil- 
laries. The  coloration  varies  also  greatly  in  different  portions  of  the 
inflamed  region.  The  posterior  wall  of  the  pharynx  is,  as  a  rule, 
the  most  heightened  in  colour,  though  sometimes  only  the  soft 
palate  will  be  hyperaemic  ;  while  in  other  cases  the  surface  of  the 
tonsils  may  be  the  sole  portion  of  abnormal  hue.  The  uvula  and 
fauces  may  be  translucent  from  cedema,  and  the  hyperasmia  in  this 
region  is  always  greater  than  in  the  lower  portion  of  the  pharynx. 

Form,  etc.,  is  modified  according  to  the  amount  of  submucous 
or  serous  infiltration.  The  surface  texture  is  at  first  shiny  and 
smooth  ;  later  it  becomes  thickened  and  velvety,  or  roughened 
and  granulated,  owing  to  prominence  of  hypertrophied  lymphoid 
glandules.  Loss  of  tissue  is  rare,  unless  the  attack  be  due  to  toxic 
or  traumatic  causes. 

Secretion  is  at  first  arrested,  causing  the  throat  to  feel  dry  and 
rough,  or  as  if  a  hair  were  in  the  throat ;  later,  it  becomes  viscid 
and  tenacious  ;  and,  lastly,  muco-purulent  or  purulent.  I  am  in 
agreement  with  ^Beverley  Robinson  in  not  recognising  fibrinous 
exudations  as  usual  or  even  occasional  concomitants  of  a  pharyn- 
gitis or  tonsillitis,  unless  the  inflammation  be  septic  or  traumatic 
in  origin,  on  this  point  differing  from  ^Bosworth.  I  am  even 
inclined  to  suspect  the  simple  catarrhal  origin  of  the  attack  when 
oedema  extends  beyond  moderate  infiltration  of  the  extremity 
of  the  uvula. 

Both  Cohen  and  Bosworth  describe  a  *  Common  Membranous 
Sore  Throat,'  each  author  agreeing  to  give  an  almost  verbally 
•exact  portraiture ;  but  it  is  not  familiar  to  me,  and  must  be  rare 
in  this  country.  It  is  said  to  be  an  acute  inflammation  of  the 
mucous  lining  of  the  pharynx,  characterized  by  the  eventual 
■exudation  of  a  fibrinous  material  which  coagulates  on  the  surface 
•of  the  membrane  into  a  pellicle  or  pseudo-membrane,  and  is 
oftentimes  mistaken  for  diphtheria.  The  accompanying  drawing 
(Fig.  CI  I.)  represents  the  nearest  approach  to  such  a  condition 
that  I  have  myself  encountered. 

It  was  taken  from  the  throat  of  a  gentleman  aged  forty,  who  had  suffered  from  acute 
rheumatism  at  seventeen,  and  had  recently  returned  from  Australia  after  a  residence  theve  of 
over  twenty  years.    During  that  time  he  had  occasionally  suffered  from  pleurodynia  and 


l82 


DISEASES  OF  THE  THROAT  AND  NOSE. 


flying  muscular  pains,  but  from  no  serious  rheumatic  attack  nor  from  sore  throat.  The 
illness  for  which  he  applied  to  me  occurred  on  the  first  approach  of  damp  and  cold 
weather  in  the  autumn  after  his  return  home.  He  complained  of  excruciating  pain  in. 
swallowing  and  talkmg,  and  on  examination  the  whole  ot  the  soft  palate  was  seen  to  be 
intensely  inflamed,  swollen,  and  relaxed,  with  enlargement  and  blocking  of  the  glandules^ 
and  very  smaH,  easily  dislodged  pellicles  of 
fibrinous  exudation,  with  some  inflammatory 
areola.  There  was  no  evidence  of  a  septic 
origin,  but  complaint  was  made  of  a  general 
aching  of  the  body  '  like  rheumatism.'  The 
tonsils  were  not  affected.  I  prescribed  ape- 
rients, salicylate  of  soda,  local  application  of 
cocaine,  and  the  sucking  of  ice  in  small  ^% 
pieces.  The  attack  subsided  in  a  very  few 
(lays. 


Fig.  CII. — Acute  Pharyngitis,  with 


In  many  respects  this  case  re- 
sembles the  accepted  description 

of  herpes  of  the   pharynx,  but  " "  sli'g'ht  ExudItion"!!-!^^^^^^^ 
there  was  no  manifestation  on  the 
lips  or  elsewhere,  nor  had  the  patient  ever  suffered  from  herpes^ 
The  exudation  was  moreover  bilateral. 

C.  Miscellaneous.  External  and  General. — The  usual  con- 
stitutional, premonitory,  and  concurrent  symptoms  of  inflam- 
matory catarrh  are  always  present,  though  they  are  greatly 
modified  according  to  the  severity  of  the  local  disease.  The 
temperature  at  the  onset  is  often  increased  out  of  proportion  to 
the  gravity  of  the  attack — this  especially  in  the  case  of  young 
children  ;  the  digestive  system  is  almost  invariably  at  fault,  the 
bowels  being  constipated,  the  urine  highty-coloured  and  loaded 
with  lithates,  the  tongue  furred,  and  the  breath  foul.  There  is 
frequently  co-existing  pain  in  the  muscles  of  the  neck,  the  loins, 
and  the  joints  of  the  body  generally,  and  headache  is  an  almost 
constant  symptom. 

Commemorative. — The  disposition  to  pharyngeal  catarrh  is 
often  inherited ;  and,  as  already  stated,  is  not  unfrequentty  asso- 
ciated with  the  scrofulous,  arthritic  or  darthous  diathesis. 

Prognosis  is  favourable,  unless  suppuration  of  deeper  tissues 
(pharyngeal  abscess)  supervenes,  or  unless  the  inflammation  ex- 
tends to  the  lar3mx.  When  sore  throat  passes  into  a  '  head  cold,' 
the  prognosis  is  always  favourable.  Convalescence  is  frequently 
delayed  by  the  disease  becoming  chronic. 

Treatment  :  Constitutional. — Free  purgation,  especially  by 
salines  preceded  by  some  form  of  mercury,  is  in  my  opinion  an 
indispensable  first  step;  aconite  in  one-drop  doses  (Form.  86), 
until  circulation  is  lowered  and  perspiration  induced,  or  the  sali- 
cylates with  chlorate  of  potash  or  sodium  (Form.  98),  each  acting 
well  where  the  inflammation  is  associated  with  rheumatism.  All 


ACUTE  PHARYNGITIS. 


183 


other  constitutional  states  predisposing  to  or  accompanying  the 
local  inflammation  require  to  be  dealt  with  on  the  lines  of  general 
therapeutics.  Frankel  advises  quinine  in  the  early  stages,  believ- 
ing that  it  often  cuts  short  an  attack.  During  convalescence^ 
alkalies,  with  vegetable  tonics  (Form.  97),  are  generally  indicated. 
To  these  arsenic  and  nux  vomica  may  often  be  usefully  added. 

Local. — Guaiacum  lozenges  (Form.  21)  relieve  capillary  engorge- 
ment ;  and,  probably,  also  act  constitutionally  where  the  diathesis 
is  arthritic.  Ice  taken  in  small  pieces  is  always  grateful ;  but  in 
some  cases  mouth-washes  or  gargles  of  warm  water  more  or  less 
medicated  are  preferred.  In  pharyngeal  disease,  steam  inhala- 
tions are  almost  always  fatiguing,  and  seldom  afford  proportionate 
relief.  Caustic  applications,  though  still  much  in  vogue,  have  not 
afforded,  in  my  experience,  sufficient  mitigation  of  suffering  to 
compensate  for  the  discomfort  they  occasion  ;  and  the  same  may 
be  said  of  astringents,  except  in  the  earliest  stages.  Glycerine  of 
tannin,  so  commonly  applied,  acts  usually  as  an  irritant,  on 
account  of  the  attraction  of  the  glycerine  for  the  fluid  elements 
at  the  mucous  membrane,  and  because,  as  has  recently  been 
proved,  tannin  does  not  contract,  but  dilates  the  bloodvessels. 
The  sucking  of  ice  or  the  use  of  a  hand-ball  spray  of  cold  water 
are  measures  perfectly  innocuous,  and  in  many  cases  act  both 
gratefully  and  beneficially.  Where  there  is  much  pain  with 
hyperemia,  cocaine  in  a  five  per  cent,  solution  may  be  used  with 
at  least  temporary  relief  and  should  be  applied  by  means  of  the 
spray ;  but  superior  to  all  remedies,  as  an  analgesic,  antiseptic, 
and  resolvent,  is  menthol,  employed  either  as  a  paint  or  spray ; 
it  may  be  necessary  to  apply  it  to  both  throat  and  nose.  Mouth- 
washes of  carbonate  of  soda  where  the  rheumatic  influence  is 
strongly  marked,  or  of  salicylate  of  soda,  or  both  combined,  are 
also  of  service.  Externally,  wet  compresses  are  of  great  utility. 
Strong  counter-irritants  are  decidedly  harmful,  nor,  in  my  practice, 
are  leeches  ever  employed. 

Operative. — If  oedema  be  excessive,  scarification  may  be  called 
for,  or  ablation  of  the  uvula  may  be  necessary,  on  account  of  the 
actual  discomfort  it  occasions,  or  of  the  irritation  of  the  larynx 
that  it  induces.  Removal  of  the  relaxed  tissue  and  cauterization 
or  curetting  of  lymphoid  granules  is,  however,  better  deferred 
until  subsidence  of  the  acute  stage,  from  the  possible  tendency 
to  sloughing,  and  because  during  an  inflammatory  attack  it  is 
not  easy  to  judge  how  much  should  be  removed.  The  nature  of 
nasal  stenosis  must  be  carefully  ascertained  and  submitted  to 
appropriate  treatment.    See  Chapters  XXV.  and  XXVI. 

Diet. — Unless  the  patient  shows  signs  of  exhaustion,  food  should 


DISEASES  OF  THE  THROAT  AND  NOSE. 


not  be  given  at  more  frequent  intervals  than  usual,  although  re- 
freshing beverages  and  simple  succulent  fruits  may  be  allowed  in 
moderation.  In  order  to  give  rest  to  the  function  of  deglutition, 
all  food  should  be  bland,  semi-solid,  and  warm.  Stimulants  are 
by  no  means  necessary,  the  favourite  port-wine  treatment  of  tra- 
dition being  a  fallacy. 

Hygiene. — Predisposing  causes,  being  carefully  ascertained, 
must  be  naturally  guarded  against,  and  in  children  the  most 
likely  predisponent  causes  should  be  promptly  and  thoroughly 
obviated.  Spring  and  autumn  being  most  favourable  to  this  form 
of  angina,  patients  should  particularly  guard  against  the  too 
sudden  changing  of  their  clothing  and  variations  of  their  habits  of 
life  indicated  by  the  alternation  of  season.  Of  all  things  the 
subjects  of  catarrhal  soar  throat  should  avoid  constipation.  When 
attacks  are  frequently  recurrent,  a  course  of  treatment  at  Aix-les- 
Bains  has  a  powerful  effect  in  diminishing  the  patient's  liability. 
Cold  baths,  and  especially  external  local  douching  with  cold  salt 
and  water,  appear  to  act  as  prophylactics  against  '  catching  sore 
throat ;'  but  in  subjects  who  suffer  from  defective  circulation,  such 
Spartan  treatment  is  by  no  means  to  be  recommended,  and  warm 
baths,  with  cold  douching,  or  the  standing  in  hot  water  during  the 
drying  of  the  body  after  a  cold  bath,  will  often  be  preferably  em- 
ployed. In  this  connection  it  may  be  usefully  hinted  that  in  many 
cases  the  sea  or  river  bath,  as  taken  in  this  country,  is  not  only 
contra-indicated,  but  is  positively  injurious. 

SUPPURATING  PHARYxNGITIS  ;  HOSPITAL  SORE  THROAT. 

These  terms  have  been  variously  applied  to  that  form  of  acute 
pharyngitis  which  occurs  in  persons  whose  system  has  become 
much  reduced  by  hard  work  under  exceedingly  unfavourable 
sanitary  conditions  of  the  inspired  atmosphere,  as  well  as,  in 
some  instances,  of  food  and  water  supply.  Thus,  amongst  its 
causes  may  be  mentioned  work  in  the  dissecting-room,  absorption 
of  septic  material  from  unhealthy  w^ounds,  the  nursing  of  patients 
suffering  from  erysipelas  and  various  fevers,  exposure  to  bad 
drainage,  drinking  unhealthy  water,  etc. 

Probably  the  pharyngitis  sometin:es  occurring  in  patients 
suffering  from  small-pox,  typhus,  and  typhoid  fevers,  is  really  of 
this  nature.  The  angina  of  scarlet  fever,  however,  is  to  be  con- 
sidered as  a  distinct  symptom,  occurring  at  an  early  period  in 
the  course  of  the  disease.  Nor  have  I  found  this  septic  form  of 
pharyngeal  inflammation  to  be  often  associated  with  either  syphilis 
or  tuberculosis. 

A  variety  of  pharyngitis  which  may  be  considered  as  belonging 


PHLEGMONOUS  PHARYNGITIS, 


■to  the  category  of  phlegmonous  inflammations,  but  not  often 
•seen  in  our  country,  is  that  described  by  *^Stoerk  as  Chronic 
hlcnnorrhcea,  and  is  endemic  in  Poland,  Galicia,  and  Wallachia. 
It  fn-st  makes  its  appearance  in  the  nose  and  naso-pharynx  in  a 
form  similar  to  the  ozsena  of  hereditary  syphilis,  and  slowly 
extends  downwards  through  the  pharynx,  larynx,  and  in  exceptional 
cases  even  to  the  trachea  and  its  bifurcations.  The  inflammation 
is  of  the  phlegmonous  type  ;  the  secretions  are  muco-purulent  in 
character,  and  are  probably  the  vehicle  for  the  spread  of  the 
disease,  which  in  its  whole  aspect  bears  a  close  resemblance  to  an 
early  throat  affection  of  syphihs,  with  this  important  difference, 
however — that  the  ulcerations  are  sluggish,  unaccompanied  by 
rapid  loss  of  tissue,  and  are  entirely  unaffected  by  specific 
treatment. 

The  particular  diagnostic  sign  of  phlegmonous  pharyngitis  is 
that  it  is  by  no  means  confined  to  the  areolar  tissue,  but  generally 
extends  to  the  deeper  structures,  leading  to  suppuration,  which 
may  involve  the  submucous  tissues,  and  may  burrow  either  be- 
neath the  deep  cervical  fascia,  or  may  point  and  open  into  the 
oesophagus.  Or,  as  is  not  unfrequently  the  case,  the  cedematous 
inflammation  extends  to  the  larynx,  to  the  imminent  danger  of 
•suffocation.  It  is  very  apt  to  take  on  a  sloughing  character,  and 
as  a  result,  severe  and  even  fatal  hgemorrhages  may  occur. 

The  tonsils  in  phlegmonous  pharyngitis  are  always,  from  the 
first,  highly  inflamed  and  greatly  swollen,  so  much  so  that  the 
disease  may  at  first  be  mistaken  for  a  tonsillitis.  Differing  from 
what  occurs  to  the  other  tissues  of  the  pharynx,  the  tonsillar 
inflammation  is  principally  of  the  mucous  membrane  and  peri- 
tonsillar connective-tissue,  and  does  not,  as  a  rule,  extend  to 
the  parenchyma  or  gland  structure  itself.  The  tonsillar  swelling 
is  usually  bilateral — a  diagnostic  point  of  distinction  from  ordinary 
quinsy — and  may  be  so  extreme  as  to  seriously  threaten  life  by 
direct  obstruction  of  respiration,  both  naso-pharyngeal  and  oral. 
The  act  of  swallowing  is  equally  distressful,  and  may  become  im- 
possible. Ulceration  may  take  place  from  the  attrition  and 
consequent  irritation  of  the  highly-inflamed  surfaces,  leading  to 
gangrene  of  varying  area  and  depth.  All  the  other  symptoms  of 
acute  tonsillitis,  to  be  later  described,  are  present  in  an  ex- 
aggerated degree.  The  glands  of  the  neck  are  often  most  pain- 
fully swollen,  rendering  every  movement  of  the  head  most 
agonizing.  As  already  hinted,  this  condition  of  the  pharynx  is 
apt  to  quickly  extend  to  the  larynx,  and  to  give  rise  to  acute 
cedematous  inflammation  of  that  region. 


i86 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  attack  is  usually  ushered  in  by  a  feeling  of  illness,  with 
languor,  headache,  etc.  Then  follows  quickly  a  rigor  with  high 
temperature,  rapid  pulse,  and  fever  ;  with  delirium  at  a  very 
early  period.  The  throat,  at  first  dry,  soon  becomes  clogged 
with  thick  foul  mucus,  and  acute  pain  in  deglutition  is  one  of 
the  first  local  symptoms.  The  general  course  of  the  disease^ 
when  its  origin  is  unassociated  with  some  specific  poison,  is  very 
much  that  of  erysipelas.  Some  authors  have  described  an  ery- 
sipelas of  the  throat  in  which  just  such  a  condition  of  that  organ 
as  now  described  is  found  associated  with  erysipelas  of  the  head, 
face,  or  neck.  It  is  unnecessary  to  point  out  that  the  etiology, 
pathology,  course  and  treatment  of  such  a  sore  throat  does  not 
differ  materially  from  that  under  present  consideration. 

Prognosis. — It  must  never  be  forgotten  that  the  forecast  of 
phlegmonous  pharyngitis  is  always  most  unfavourable,  there  being 
a  very  great  tendency  to  sloughing,  to  extension  of  the  disease 
into  the  larynx,  and  to  general  septicaemia.  There  are  also  the 
dangers  of  suffocation  already  alluded  to,  as  well  as  of  the  bursting 
of  abscesses  into  the  oesophagus,  the  passage  of  pus  into  the 
trachea  during  sleep,  or  of  haemorrhage  from  extension  of  ulceration 
into  some  of  the  larger  vessels  of  the  neck.  The  duration  of  the 
attack  is  from  three  days  to  a  fortnight.  Convalescence  is  always 
tedious,  and  accompanied  by  many  complications  when  suppura- 
tion has  been  extensive.  Temporary  paralysis  of  the  muscles  of 
palate,  fauces,  and  pharynx  is  a  not  unusual  sequel.  The 
prognosis  of  an  external  erysipelas  that  extends  to  the  mucous 
membrane  of  the  throat  is  always  most  grave. 

Treatment. — The  constitutional  symptoms  being  of  much 
greater  import  than  in  simple  pharyngitis,  general  treatment 
must  receive  special  and  prompt  attention,  local  measures  being, 
however,  by  no  means  neglected. 

Great  importance  is  to  be  attached  to  tonics,  especially  iron, 
chlorate  of  potash,  and  bark,  and  stimulants  in  large  quantities 
are  often  indicated.  Of  local  remedies,  one  of  the  first  in  import- 
ance is  the  application  of  cold  externally  by  the  Leiter  coil, 
cloths  wet  with  ice,  cold  water,  and  the  like,  and  the  sucking  of 
ice  or  taking  of  iced  drinks.  The  surgeon  is  often  tempted  to 
make  incisions  and  scarifications  to  relieve  pressure,  but  such 
wounds  almost  invariably  slough,  and  should  not  be  made  unless 
there  is  distinct  evidence  of  pus  pointing  at  the  point  to  be  incised. 
It  is  right  to  add,  however,  that  Stoerk,  Frankel,  and  Schech 
advise  free  incisions  even  where  there  be  no  pus  liberated, 
believing  that  this  measure  gives  relief  to  tension,  and  by  the 
blood-letting  diminishes  the  inflammation.    Scarification  of  the 


POST-  OR  RETRO-PHARYNGEAL  ABSCESS. 


187 


larynx  is  an  operation  often  recommended  in  books,  but  is  not 
easy  of  performance  when  the  fauces  are  swollen. 

Tracheotomy  is  not  unfrequently  called  for,  on  account  of 
dyspnoea  from  extension  of  oedema  into  the  larynx,  but,  unfor- 
tunately, in  too  many  instances  the  patient  fails  to  rally  after  its 
performance.  In  cases  of  erysipelas  the  disease  will  be  almost 
certain  to  extend  to  the  tracheal  incision. 

Where  obstruction  to  respiration  is  due  to  enlargement  of  the 
tonsils,  it  is  better  to  excise  those  glands  before  proceeding  to 
the  major  operation  of  opening  the  windpipe. 

As  a  precaution  against  recurrence,  hypertrophic  rhinitis  and 
septal  spurs  must  be  searched  for  and  treated. 

Independently  of  the  erysipelatous  variety  of  hospital  sore 
throat  just  described  one  occasionally  sees  a  milder  form  of 
ulcerative  septic  pharyngitis  and  tonsillitis  in  the  persons  of 
those  closely  engaged  in  post-mortem  and  dissecting  rooms,  and 
also — but  not  so  frequently  in  these  days  of  Listerism — in  surgical 
wards.  The  symptoms  are  those  of  faucitis,  without  marked 
oedema,  but  resulting  in  actual  ulcerations  of  a  limited  lenticular 
shape,  shallow,  and  covered  with  a  gre}^  pellicle,  equally  distinctive 
from  the  yellow  caseous  excretions  of  lacunar  tonsillitis,  the  opales- 
cent mucous  patch  of  secondary  syphilis,  the  excavating  ulcer  of 
tertiary  disease,  or  the  tough  membranous  deposit  of  diphtheria. 
Constitutional  disturbance  may  be  out  of  all  proportion  to  the 
often  slight  local  lesion. 

Treatment  consists  primarily  in  removal  of  the  patient  from 
the  area  of  contamination,  with  change  to  the  country  or  seaside* 
Such  cases  will  then  speedily  recover  under  local  antiseptics  and 
general  tonic  treatment.  Cauterizations  so  usually  adopted  are 
of  doubtful  utility.  Persistence  in  duty  not  only  render  all  treat- 
ment futile,  but  may  lead  to  the  development  of  the  graver  form 
of  malady. 

POST-  OR  RETRO-PHARYNGEAL  ABSCESS. 

General  diffuse  suppuration  of  the  pharynx  is  fortunately  a  very 
unusual  termination  of  acute  inflammatory  attacks  in  this  region. 
M^hen  it  does  occur,  it  is  usually  in  that  form  of  sore  throat 
arising  from  the  poison  of  a  fever  or  of  a  tainted  atmosphere, 
which  has  been  already  described  under  the  heading  of  '  Phleg- 
monous Pharyngitis.' 

Etiology  and  Pathology. — Circumscribed  abscess  of  the 
pharynx  is  a  most  rare  circumstance,  and  few  surgeons  or 
specialists  can  recount  more  than  from  three  to  five  cases  in  their 
own  individual  experience.    "Bokai,  to  whom  we  are  much  in- 


DISEASES  OF  THE  THROAT  AND  NOSE, 


debted  for  the  correction  of  many  errors  concerning  the  disease, 
only  reported  204  cases  as  occurring  in  the  Children's  Hospital,  at 
Pesth,  during  a  period  of  twenty-six  years.  Since  the  publication 
of  Bokai's  monograph,  it  has  been  generally  assumed  that  the 
disease  is  mainly  one  of  childhood ;  but  for  myself,  I  may  say 
that  with  an  experience  of  twenty  years  of  out-patient  work  in 
institutions  treating  on  an  average  5,000  cases  a  year  of  disease 
in  the  region  involved,  I  have  seen  but  two  cases  which  occurred 
in  children,  as  against  four  in  adults.  By  parity  of  reasoning, 
the  cause  I  suggest  of  fallacious  deductions  in  Bokai's  statistics, 
namely,  the  specialized  narrowness  of  his  sphere  of  observations, 
might  be  adduced  against  my  somewhat  opposed  experience  ;  but 
this  could  be  true  only  in  degree,  for  children,  even  infants,  if 
suffering  from  throat  symptoms,  are  brought  to  Throat  Hospitals 
in  large  numbers. 

Formerly,  retro-pharyngeal  abscess  was  supposed  to  be  almost 
always  associated  with  caries  of  one  or  more  cervical  vertebrae,  or 
of  the  cartilages  of  the  larynx ;  but  it  is  now  conceded  that  but 
few  are  due  to  this  cause,  and  it  is  generally  recognised  as  due 
to  a  phlegmonous  inflammation  of  the  loose  connective-tissue 
between  the  pharynx  and  the  vertebral  column,  or  of  that  between 
the  pharynx  and  larynx  ;  and  in  a  still  larger  number  of  cases  as 
a  suppurative  lymphadenitis,  the  origin  of  which  is  in  the  deep 
lymphatic  glands  w^hich  are  situated  on  each  side  ot  the  second  and 
third  vertebrae,  and  which  are  particularly  large  in  the  earlier 
years  of  life.  There  are  thus  two  distinct  classes  of  retro-pharyn- 
geal abscess  to  be  recognised,  those  connected  with  the  soft  parts 
and  those  occurring  as  a  result  of  caries  of  the  spinal  column.  I 
agree  with  ^Lefferts,  that  nasal  disease  is  but  a  rare  cause  of  the 
affection  under  notice,  and  the  same  may  be  said  of  aural  affec- 
tions, sometimes  quoted  as  etiological  factors  of  post-pharyngeal 
suppuration.  But  very  few  cases  occur  as  sequelae  of  other 
diseases,  those  reported  being  generally  observed  as  a  complica- 
tion of  scarlet  fever,  of  diphtheria,  and  of  acute  suppuration  of 
the  middle  ear.  Other  causes  are  traumatism  of  a  foreign 
body,  and  metastasis,  of  which  ^Nelaton  has  reported  examples 
in  connection  with  perinaeal  suppuration.  A  case  is  at  present 
(November,  18S6)  under  the  care  of  my  colleague.  Dr.  Dundas 
Grant,  in  which  the  first  cause  was  lodgment  of  a  fish-bone. 
This  was  followed  by  abscess  and  post-pharyngeal  sinus,  necrosis 
of  vertebra,  and  later  by  pyaemia.  The  dyscrasi^  predisposing 
to  the  disease  are  scrofula  and  syphilis.  I  have  seen  two  cases 
in  adults,  in  whom  it  was  not  possible  to  obtain  a  venereal 


POST-PHARYNGEAL  ABSCESS. 


history,  and  in  these  the  malady  appeared  to  be  due  to  exposure 
to  wet  and  cold,  with  indifferent  general  surroundings  of  food 
and  dwelling-place. 

Symptoms  :  A.  Functional. — The  local  signs  are  not  often 
manifested  until  the  disease  has  made  considerable  advance.  The 
chief  sign  is  that  of  dysphagia,  the  swelling  causing  a  mechanical 
obstruction  to  the  passage  of  food  ;  this  is  not,  however,  an  in- 
variable sign.  Coupled  with  it  there  is  possibly  dyspnoea,  especially 
if  the  abscess  presses  against  the  larynx,  or  induces  oedema  of  the 
glottis.  The  respiration  is  almost  always  stertorous,  and  when 
the  larynx  is  complicated  it  is  stridulous.  Cough  of  the  nature 
recognised  as  due  to  the  effort  to  clear  the  throat  of  a  foreign 
body  is  a  common  evidence,  and  especially  when  the  post-pharyn- 
geal  obstruction  presses  against  the  larynx,  or  when  there  is 
secondary  cedematous  laryngitis;  the  voice  is  thick  and  void 
of  nasal  resonance.  All  functional  efforts  are  followed  by  extreme 
general  exhaustion.  A  very  characteristic  symptom,  when 
there  is  vertebral  disease,  is  the  pain  occasioned  by  movement 
of  the  head  on  the  spinal  column,  causing  the  patient  to 
keep  the  head  quite  stiff  when  the  abscess  is  in  the  middle  line,, 
or  to  incline  it  away  from  the  affected  side  when  the  suppuration 
is  situated  in  one  or  other  lateral  space.  In  children  convulsions 
and  spasms  are  not  unfrequently  witnessed. 

B.  Physical. — With  the  reflected  light  of  the  frontal  mirror  a 
large  swelling  may  often  be  observed,  the  diagnosis,  especially  in 
the  case  of  adults,  being  assisted  by  use  of  the  laryngeal  mirror ; 
palpation  with  the  index-finger  will  show  the  tumour  to  be  of 
*  doughy,'  semi-elastic  consistence  ;  by  the  same  means  the 
presence  of  pus  may  be  frequently  determined.  Examination  by 
this  method  should  never  be  neglected.  It  presents  no  difficulty, 
if  the  finger-guard  be  employed,  and  does  not  appear  to  require 
pre-administration  of  chloroform,  as  has  been  advised  by  some 
authors. 

Prognosis  is  very  grave  where  there  is  spinal  caries,  but  cases 
have  not  been  wanting  of  a  favourable  termination.  In  children 
there  is  also  the  additional  risk  of  suffocation  from  bursting  of  the 
abscess  during  sleep.  The  most  favourable  prospect  is  afforded 
in  those  cases  in  which  early  diagnosis  being  made,  prompt  pre- 
cautions are  taken  against  any  such  danger. 

Treatment. — Some  surgeons  recommend  great  caution  in 
the  evacuation  of  pus  in  these  cases ;  but  I  have  seen  no 
untoward  result  from  a  free  opening  with  the  laryngeal  lancet. 
The  only  precautions  necessary  are,  first,  to  keep  the  incision  as 


I90 


DISEASES  OF  THE  THROAT  AND  NOSE. 


nearly  as  possible  in  the  mesial  line,  so  as  to  avoid  wounding 
the  internal  carotid,  and  then  to  incline  the  patient's  head  for- 
ward so  as  to  prevent  passage  of  pus  into  the  larynx.  Artificial 
feeding  by  an  oesophageal  tube  may  be  required  for  a  lengthened 
period,  especially  in  those  cases  in  which  there  is  fistulous  com- 
munication with  the  larynx.  Iodide  of  iron,  with  cod-liver  oil, 
etc.,  is  almost  always  serviceable  as  an  aid  to  convalescence,  and 
other  suitable  constitutional  remedies  are  to  be  administered 
w^herever  the  dyscrasiae  give  the  practitioner  indications  of  their 
requirement. 

SUBACUTE  PHARYNGITIS  (Fig.  13,  Plate  11.). 

All  the  functional  symptoms  of  the  acute  disease,  modified  in 
intensity,  are  present  in  this  form.  It  is  often  seen  in  association 
with  the  milder  exanthemata,  as  chicken-pox,  measles,  and  rotheln 
(Fig.  16,  Plate  II.).  When  associated  with  eczema,  herpes,  or 
aphtha,  to  which  allusion  was  made  in  the  prefatory  remarks  of 
this  chapter,  the  type  is  generally  of  the  subacute  grade. 

Symptoms  :  A.  Subjective. — Voice  is  easily  fatigued  and 
somewhat  hoarse,  due  to  laryngeal  irritation,  and  it  may  be  to 
.rheumatic  inflammation  of  the  muscles. 

Cough  is  tickling  and  irritable,  but  seldom  or  never  painfuL 

Deglutition  is,  without  being  exactly  painful,  performed  with 
undue  consciousness,  and  there  is  a  frequent  desire  to  swallow 
the  saliva,  or  to  exercise  the  muscles  of  the  fauces  and  pharynx. 

Pain  is  neither  constant  nor  acute,  and  varies  greatly  with  the 
temperament  of  the  individual. 

B.  Physical. — Colour  is  increased,  but  by  no  means  uniformly, 
over  the  whole  surface  :  for  instance,  the  pillars  of  fauces  and 
uvula  may  be  hyperaemic,  while  the  rest  of  the  surface  is  normal ; 
or  one  side  of  the  throat  only  may  be  red,  while  the  other  is 
unaffected. 

There  may  be  some  swelling  and  thickening,  and  there  is 
■  generally  some  disorder  of  secretion,  it  being  increased  in  quantity, 
and  changed  in  quality  from  a  clear  viscidity  to  a  thick  yellowish, 
or  even  greenish  fluid.  When  associated  with  the  exanthemata 
above  mentioned,  the  cutaneous  manifestations  will  be  reproduced 
with  slight  modifications  on  the  mucous  membrane.  Constitu- 
tional symptoms  are  but  of  slight  importance. 

Treatment  being  commenced,  as  is  always  necessary,  with 
purgatives,  may  be  almost  confined  to  local  measures.  Guaiacum 
lozenges  (Form.  21)  are  most  suitable  if  there  is  any  soreness, 
or  if  the  pillars  of  the  fauces  are  inflamed :  astringent  lozenges 


CHRONIC  PHARYNGITIS. 


(Form.  12,  i6,  17,  and  23)  and  gargles  (Form.  5)  are  indicated  if 
the  pendulous  soft  palate  be  the  region  affected. 

With  reference  to  prophylaxis,  no  person  liable  to  these  attacks, 
seeing  the  part  digestion  plays  in  them,  should  take  sparkling 
wines,  beer,  or  any  fluid  containing  partially  fermented  sub- 
stances. I  am  also  in  the  habit  of  forbidding  pastry,  preserves, 
and  root  vegetables,  as  turnips,  carrots,  parsnips,  and  radishes. 

The  hygienic  directions  recommended  to  persons  subject  to 
the  acute  form  of  sore  throat  are  also  to  be  observed  by  those 
subject  to  the  milder  attacks. 

CHRONIC  PHARYNGITIS— CLERGYMAN'S  OR  VOICE-USER'S  SORE 
THROAT  (Figs.  14,  15,  18,  and  19,  Plate  IL,  and  Fig.  112,  Plate  XIII.). 

This  form  of  pharyngitis  must  not  be  confounded  with  chronic 
^follicular'  tonsillitis,  as  is  sometimes  the  case,  but  from  which  it  is 
quite  distinct.  It  may  occur  simply  as  a  sequel  of  the  acute  or 
subacute  form,  or  it  may  be  caused  by  one  of  other  of  the 
influences  about  to  be  mentioned.  It  may  be  present  simply 
:as  a  more  or  less  general  congestion  (Plate  II.,  Fig.  14),  with 
thickening  of  the  pillars  of  the  fauces,  and  having  no  distinctive 
features,  except  its  chronicity,  from  the  subacute  form  (Fig.  13), 
or  the  throat  may  present  the  appearances  which  have  led  to 
the  use  of  the  various  terms — granular,  glandular,  follicular,  or 
herpetic  pharyngitis  (Figs.  18  and  19).  Looking  on  the  pathology 
of  the  disease  as  one  of  venous  congestion,  leading  to  perversion 
of  secretion  with  more  or  less  enlargement  of  the  follicles  of  the 
pharyngeal  mucous  membrane,  I  do  not  recognise  these  distinc- 
tions, and  propose  to  consider  all  these  disorders  under  one 
heading.  Equally  misleading  are  such  subdivisions  as  hyper- 
trophic and  exudative.  ^'^Morell- Mackenzie,  in  detailing  the 
•objective  symptoms  of  *  Clergyman's  Sore  Throat,'  gives  a 
■description  of  an  *  exudative  form  of  follicular  pharyngitis,'  which 
is,  in  point  of  fact,  a  very  fair  picture  of  so-called  follicular 
tonsillitis,  with  which  he  in  so  many  words  confuses  it.  But  it 
need  hardly  be  pointed  out  that  in  etiology,  pathology,  and  other 
indications  for  treatment,  the  two  diseases  are  quite  distinct ;  and 
their  consideration  as  one  is  surprising  in  an  author  who  seldom 
errs  on  the  side  of  generalization. 

Etiology. — Chronic  pharyngitis  may,  in  a  measure,  be  due  to 
disorders  of  either  the  glandular,  the  nervous,  or  the  digestive 
system  ;  thus  its  causation  may  be  connected  indiscriminately 
with  phthisis,  with  venereal  excesses,  or  with  chronic  alcoholism ; 
over-use  of  .tobacco  is  also  assigned  as  a  cause,  and  in  such  cases 


192 


DISEASES  OF  THE  THROAT  AND  NOSE. 


It  will  often  be  found  that  the  subject  has  been  in  the  habit  of 
frequently  expectorating  during  smoking,  and  has  thus  perverted 
the  normal  secretion.  In  other  cases,  the  pharyngitis  maybe  due- 
to  the  effect  of  nicotine  on  the  vaso-motor  system  ;  or,  again,  it 
may  be  induced  by  direct  irritation  of  particles  of  tobacco,  as  in 
snuff-takers.  With  respect  to  the  connection  between  pharyngitis 
and  certain  diatheses  and  diseases  in  other  parts  of  the  body^ 
neither  acne  nor  herpes,  according  to  my  experience,  plays  an 
important  part  as  a  cause,  as  has  been  stated  by  ^^Isambert  and 
other  French  authors.  I  have  found  many  patients  the  subject 
of  chronic  pharyngitis  who  were  not  subject  to  any  form  of  acne 
or  herpes ;  but  seeing  that  such  affections,  as  well  as  granular 
pharyngitis,  are  due,  in  some  measure,  to  disorder  of  the  portal 
circulation  or  to  vaso-motor  weakness,  it  is  not  surprising  that 
they  should  sometimes  co-exist.  Whereas,  however,  these  skin 
affections  require  little  or  no  local  treatment,  it  is  certain  that  no 
form  of  exclusively  constitutional  remedy  will  remove  granulations 
from  a  chronically  congested  pharynx. 

Among  the  most  proHfic  causes  of  chronic  pharyngitis  must  be 
reckoned  improper  use  of  the  voice.  By  this  expression  must  be 
understood  not  simply  improper  voice-production,  improper  use 
or  over-exertion  of  voice,  which  may  mean  forcing — an  act  entirely 
controlled  by  the  pharynx — but  also  use  of  the  voice,  whether 
rightly  or  wrongly  produced,  at  improper  periods  ;  for  instance, 
public  speaking,  during  catarrhal  attacks,  as  in  clergymen  and 
actors,  with  whom  the  exercise  of  the  function  is  a  professional 
necessity ;  in  inclement  weather,  or  under  unfavourable  circum- 
stances of  surrounding  noise,  causing  the  individual  to  speak  in  too 
lo-ud  a  voice,  as  with  military  men  on  the  field  of  battle,  open-air 
preachers  and  politicians,  auctioneers  in  the  dust  of  sale-rooms, 
and  hawkers  and  costermongers  exposed  to  the  influence  of  noisy 
streets  and  vehicles.  Certain  it  is  that  this  affection  occurs  more 
frequently  in  professionally  voice-using  subjects  who  have  not,  as 
a  rule,  had  proper  voice-training.  The  particular  faults  in  voice- 
production,  giving  rise  to  chronic  pharyngitis,  have  been  dwelt 
on  by  us  at  great  length  in  V'oicc,  Song,  and  Speech.  They  have 
been  well  described  by  ^-Carl  Seller  as  due  to  repeated  transgres- 
sion of  the  natural  limits  of  the  normal  registers  of  the  voice,  and 
the  modus  operandi  of  the  pathological  process  has  been  accurately 
explained  by  him.  Another  main  cause  of  the  disorder  is  m.outh- 
breathing,  due  to  nasal  stenosis,  whatever  the  origin  thereof. 

Finally,  it  is  almost  universally  admitted  that  chronic  pharyn- 
gitis is  very  frequently  the  sequel  of  oft-recurring  acute  attacks. 

Pathology. — Chronic  pharyngitis  differs  from  the  acute  form, 


CHRONIC  PHARYNGITIS. 


193 


not  only  as  regards  its  duration  and  course,  but  also  in  as  much 
as  the  hypersemia  is  less  intense  and  less  diffuse,  and  is  not  ac- 
companied by  so  much  general  swelling.  On  the  other  hand, 
enlargement  of  the  glandules  in  isolated  groups,  or  in  large 
patches,  is  oftener  observed  during  chronic  than  during  acute 
inflammation  in  this  region  ;  and  engorgement  of  the  superficial 
veins  of  the  pharynx — a  condition  never  present  in  acute  catarrh 
— is  quite  common  in  the  chronic  form.  The  morbid  process  by 
which  a  throat  arrives  at  a  chronically  inflamed  condition  has 
been  touched  on  in  treating  of  its  causation.  In  vocal  cases  it 
appears  to  be  purely  of  the  nature  of  a  glandular  hypertrophy,  the 
result  of  an  over-loading  of  the  vessels  by  misdirected  force  ;  in 
others  by  causes  which  diminish  vaso-motor  control.  Concurrently 
with  this  overgrowth,  the  secreted  nr.aterial  becomes  changed  in 
character,  being  first  excessive  in  quantity,  then  deficient  in  fluid 
elements,  and  finally  diminished  in  both  quantity  and  moisture. 
This  last  condition  represents  the  dry  stage — Pharyngitis  sicca — 
which  has  also  received  as  synonymous  the  term  atrophica,  because 
at  this  period  of  the  disease  there  is  a  distinct  wasting  of  the 
mucous  membrane  and  of  the  glandular  structures  of  the  diseased 
region,  the  atrophy  being  limited  to  the  posterior  wall  of  the 
pharynx,  and  to  the  naso-pharyngeal  cavity  and  its  contents. 
There  is  little  doubt  but  that  in  many  cases  this  atrophy  is  an 
advanced  stage  of  the  hypertrophic  inflammation,  though  it  may 
also  occur  as  a  primary  affection.  The  process  does  not  attack 
all  parts  equally,  and  wasted  tracts  will  often  be  observed  side  by 
side  with  hypertrophied  granulations. 

There  is  a  variety  of  pharyngitis  which  has  not  been  described 
by  writers  of  this  country,  but  has  for  some  years  been  de- 
nominated by  Continental  specialists  as  Pharyngitis  lateralis 
hyper trophica.  This  term  is  not  to  be  confounded  as  simply 
representing  a  condition  opposed  to  that  of  atrophic  pharyngitis, 
since  it  is  limited  by  its  sponsors  to  inflammatory  thickening  of 
the  lateral  bands.  Since  my  attention  was  drawn  to  it,  I  have 
been  on  the  look-out  for  such  a  lesion  as  representing  a  separate 
variety  of  pharyngeal  inflammation,  and  my  impression  is  that  its 
claim  to  this  distinction  has  been  somewhat  exaggerated.  Never- 
theless it  is  certainly  true  that  in  obstinate  cases  of  chronic 
pharyngitis  one  may  sometimes  see  a  persistent  redness  with 
swelHng,  either  continuous  or  beadlike,  of  the  tissues  immediately 
behind  the  posterior  pillars,  in  the  situation  of  the  salpingo- 
pharyngeal fold  ;  and  I  have  observed  this  condition  particularly 
in  those  cases  in  which  the  inflammatory  process  has  extended 

13 


194 


DISEASES  CF  THE  THROAT  Ar^D  NOSE, 


along  the  Eustachian  tube,  and  has  led  to  defect  of  hearing.  But 
I  hardly  think  that  such  a  lesion  is  ever  seen  as  an  early  or 
separate  manifestation  of  a  chronic  pharyngitis.  In  my  judgment 
it  simply  represents  a  variety  of  degree,  or  an  advanced  stage  of 
the  general  pharyngeal  inflammation.  Nor,  to  anticipate  some- 
what, have  we  found  it  necessary  to  advise — as  is  done  by  our 
Continental  confreres — the  cutting  away  bodily  by  the  knife,  or 
wholesale  destruction  by  the  cautery,  of  these  more  or  less  pro- 
nounced hypertrophies  of  normal  structures. 

The  accompanying  drawing  (Fig.  CIII.)  illustrates  this  condition.  It  will  be  seen  that 
with  the  exception  of  a  few  granulations  in  the  centre  of  the  posterior  wall,  the  inflamma- 
tion is  confined  to  the  parts  above  indicated.  The  subject  was  a  clergyman,  aged  forty, 
who  had  been  under  my  care  four  years 
previously  for  chronic  relaxation  of  his 
uvula,  and  varix  at  the  base  of  the  tongue. 
The  uvula  had  been  reduced  and  the 
varicose  veins  destroyed  by  galvano- 
cautery,  and  the  cure  had  been  confirmed 
by  a  course  at  Aix-les-Bains.  From  that 
time  the  patient  had  not  suffered,  but  for 
eighteen  months  he  had  been  without  a 
curate,  in  addition  to  the  fact  that  his 
church  was  a  large  one.  He  confessed 
that  he  had  used  his  voice  on  several  oc- 
casions with  great  effort.  The  immediate  cause  of  his  breakdown  was  the  performance 
of  four  services  without  any  aid  in  one  day,  eight  days  previous  to  his  visit.  On  his 
coming  to  me  his  voice  was  almost  entirely  gone,  and  in  consequence  of  peripheral 
irritation  of  the  superior  laryngeal  nerve,  there  was  almost  constant  spasmodic  cough, 
which  had  prevented  him  from  sleeping  for  three  nights.  He  also  experienced  pain  and 
a  sensation  of  rawness  ;  this  last  being  produced,  as  he  thought,  by  the  incessant  cough. 

Allusion  has  been  made  to  the  influence  of  tobacco  in  producing 
chronic  pharyngitis,  and  the  subject  has  received  detailed  discus- 
sion by  me  in  a  separate  monograph  already  quoted.  It  is  of 
interest  to  record  that  Ramon  de  la  Sota,  of  Seville,  describes 
several  varieties  of  pharyngitis,  which  he  considers  as  the  direct 
pathological  effects  of  the  action  of  tobacco.  They  are  of  three 
kinds :  (i)  An  erythema,  occurring  for  the  most  part  in  persons 
who  do  not  smoke  excessively,  or  who,  without  smoking,  are 
habitually  accustomed  to  an  atmosphere  charged  with  tobacco- 
smoke.  He  has  often  witnessed  this  appearance  in  the  case  of 
ladies  whose  fathers,  husbands,  sons,  or  brothers  are  always 
smoking  in  their  presence — as  is  the  custom  in  Spain,  where  one  | 
does  not  deprive  himself  of  his  cigar  either  at  table,  in  the  drawing- 
room,  or  even  in  the  bedroom.  This  observation  is  in  direct 
contradiction  to  the  less  practical  suggestion  of  Cohen,  founded, 
presumabl}^  on  less  extensive  experience,  that  *  a  cause  of  this 


Fig.  CHI.— Chronic  Pharyngitis 
Lateralis. 


CHRONIC  PHARYNGITIS. 


kind  must  be  very  infrequent  in  females,  even  in  regions  where 
women  smoke.'  (2)  The  vesicular  form,  met  with  in  those  smoking 
strong  cigars,  and  who  also  chew.  This  condition  is  one  of  some 
acuteness,  lasting  about  a  fortnight,  and  then  returning  to  a 
chronic  erythema,  or  proceeding  to  the  more  advanced  stage, 
(3)  the  granular  form,  which  is  observed  not  only  in  inveterate 
smokers,  but  in  the  makers  of  cigars  and  cigarettes,  who  live 
constantly  in  an  atmosphere  saturated  with  the  dust  and  emana- 
tions of  the  tobacco-plant.  It  is  also  seen  in  snuff-takers.  The 
special  symptoms  are  a  constant  dryness,  with  persistent  desire 
to  clear  the  throat  of  a  foreign  substance  and  a  steady  deteriora- 
tion of  voice,  which  becomes  veiled  and  toneless. 

Symptoms  :  A.  Functional. — The  Voice  is  hoarse,  often  jerky 
and  altogether  out  of  control.  This  is  not  from  any  want  of  power 
of  co-ordination  of  the  laryngeal  muscles,  nor  often  from  any  con- 
gestion of  the  vocal  cords,  which  condition  may  or  may  not  be 
present,  but  from  spasm  of  the  pharynx,  and  by  irritation  of  the 
superior  laryngeal  nerve  from  a  similar  condition  of  the  tensors  of 
the  vocal  cords.  The  voice  becomes  very  quickly  fatigued,  and 
suffers  deterioration  the  longer  it  is  exercised,  so  that  a  clergyman 
after  his  third  service  will  hardly  be  able  to  speak  above  a  whisper, 
and  will  remain  quite  hoarse  for  a  day  or  two.  Such  trouble  is 
more  frequent  in  those  subjects  who  use  the  voice  only  occa- 
sionally; thus,  a  clergyman  having  daily  service,  or  a  barrister  in  full 
practice,  will  be  less  liable  to  be  affected  than  he  who  works  the 
voice  on  Sundays  only,  or  who  makes  but  occasional  harangues. 

The  singing  voice  loses  in  power  at  either  limit  of  the  register, 
and  is  frequentty  out  of  tune,  of  which  the  patient  is  conscious. 

Respiration. — Oral  respiration  is  unaffected,  but  nasal  breath- 
ing is  often  impeded  on  account  of  glandular  hypertrophy  in 
the  vault  of  the  pharynx,  and  moreover,  in  the  great  majority 
of  cases,  by  actual  intra-nasal  disease.  Breath-taking,  in  use  of 
the  voice,  is  generally  described  as  laborious  and  painful.  Inspira- 
tion is  often  shallow  and  inefficient,  and  control  of  the  breath  in 
intonation  is  inadequate. 

Cough  is  frequent,  irritable,  and  hacking,  with  expectoration  of 
pellets  of  mucus  from  the  supra-glottic  portion  of  the  larynx  ;  and 
with  occasional  streaks  of  blood  from  the  naso-pharynx ;  epistaxis 
sometimes  occurs,  and  gives  marked  relief  to  the  local  symptoms. 

Deglutition. — The  patient  experiences  a  frequent  desire  to 
swallow,  the  sensation  arising  not  only  from  the  presence  of  quasi 
foreign  bodies,  but  also  from  an  impulse  to  get  rid  of  accumulated 


10  DISEASES  OF  THE  THROAT  AND  NOSE. 

mucus.  Pain  is  experienced  in  swallowing  hot  fluids  and  piquant 
dishes. 

The  senses  of  smell  and  of  taste  are  but  very  slightly  affected, 
even  when  the  disease  has  extended  to  the  naso-pharynx  ;  nor 
when  the  nostrils  are  obstructed  is  there  often  impediment  to  the 
odoriferous  particles  reaching  the  olfactory  'places,'  the  respi- 
ratory portion  being  that  generally  impHcated. 

Hearing  is  frequently  impaired,  from  the  collection  of  viscid 
secretion  about  the  pharyngeal  orifices  of  the  Eustachian  tubes, 
and  occasionally  from  extension  of  the  congestion  or  inflamma- 
tion to  the  middle  ear. 

Pain  is  by  no  means  a  constant  or  ordinary  symptom  of  chronic 
pharyngitis  independently  of  the  fatigue  experienced  on  functional 
exercise,  but  occasionally  the  sensation  of  a  foreign  body  and  the 
discomfort  of  spasmodic  muscular  contraction  is  so  extreme  as  to 
constitute  real  distress,  and  to  even  prevent  the  patient  resting  at 
night. 

B.  Physical. — With  regard  to  the  local  condition  of  the  surface 
in  this  disease,  some  authors  describe  it  as  one  of  ulceration  with 
granulations.  This  is  a  mistake  ;  there  is  no  ulceration.  There 
is  frequent  depression  from  atrophy  of  some  portions  of  the 
submucous  tissue,  with  elevation  of  other  parts  from  presence  of 
weak  granulations,  but  nowhere  is  there  actual  loss  of  surface- 
tissue.  This  atrophy  of  submucosa  is  particularly  noticeable  in 
the  track  leading  up  to  the  mouth  of  the  Eustachian  tubes  (show- 
ing as  a  broad  whitish  path  on  either  side.  Fig.  ig,  Plate  II.)> 
the  whole  of  the  rest  of  the  surface  being  covered  with  granules 
of  varying  sizes. 

Colour. — The  mucous  membrane  is  always  congested,  but  not 
always  uniformly  so  ;  thus  it  is  very  common  to  see  only  the 
anterior  arch  and  the  lower  part  of  the  posterior  pillars  heightened 
in  colour,  while  the  rest  is  normal  (Fig.  14).  Where,  as  in  this 
case,  the  disease  is  chronic,  the  whole  mucous  membrane  is  seen 
to  be  traversed  with  injected  capillaries,  or  the  whole  surface  may 
be  red  and  the  submucous  tissue  so  infiltrated  as  to  greatly  inter- 
fere with  nasal  respiration,  as  in  Plate  II.,  Figs.  13  and  15. 
When  the  disease  is  advanced  to  the  granular  stage,  the  posterior 
pharyngeal  wall  is  seen  to  be  uneven  in  surface  and  mottled  in 
colour,  with  numerous  strongty-marked  tortuous  lines  of  engorged 
veins  and  capillaries  (Figs.  18  and  19)  ;  this  same  varicose  con- 
dition extending  in  many  cases  to  the  vessels  at  the  base  of  the 
tongue.  The  pillars  of  the  fauces — sometimes  anterior  or  posterior 
separately,  and  often  both — are  usually  red,  with  whitish  tracks 


CHRONIC  PIIA  R YNGITIS. 


197 


close  to  the  posterior  arch,  as  above  mentioned,  leading  towards 
the  orifice  of  the  Eustachian  tubes  (Fig.  19).  The  enlarged 
glandules  appear  as  red,  pale-rose,  or  yellowish  semi-transparent 
prominences.  The  depressions  are  often  covered  with  frothy- 
saliva  or  more  or  less  tenacious  mucus.  In  the  dry  or  atrophic 
variety,  this  mucus  is  often  of  a  brownish  or  greenish  colour 
(Fig.  112,  Plate  XIII.).  In  the  case  of  snuff-takers,  and  in 
patients  exposed  to  work  in  atmospheres  charged  with  solid 
particles,  as  sweeps,  miners,  and  coal-heavers,  the  coloration  of 
the  back  of  the  throat  will  be  influenced  by  their  presence. 

Form  and  Texture. — Alterations  of  form  are  but  of  surface 
character.  Deposits  are  often  seen  on  the  uvula  which  look  like 
tubercles  :  they  are  merely  caused  by  an  arrest  of  the  glandular 
secretion,  and  are  not  nodules  of  tubercle.  This  condition  is 
illustrated  in  Plate  IV.,  Fig.  32.  Attention  has  already  been 
drawn  to  the  thickening  behind  the  posterior  pillars  in  the 
lateral  hypertrophic  variety. 

Secretion  of  the  glands  and  glandules  is  at  first  excessive,  and 
there  is  considerable  increase  of  fluid  in  the  mouth,  so  that  the 
patient  complains  that  when  speaking  he  does  not  know  how  to 
get  rid  of  his  saliva.    Very  speedily,  however,  with  continuance  of 
stimulation,  the  ordinary  catarrhal  changes  take  place,  the  mucus 
becoming  more  viscid,  tenacious,  and  even  muco-purulent.  Lastly, 
in  some  cases,  the  glandular  tissue  becomes  worn  out,  as  it  were, 
atrophy  of  the  mucous  membrane  ensuing,  and  the  throat  ex- 
hibiting a  dry  glazed  condition,  giving  rise  to  the  state  already 
described  as  pJiaryiigiiis  sicca  (Fig,  37,  Plate  V.,  and  Fig,  112, 
Plate  XIIL).    The  secretion  is  in  such  circumstances  so  tenacious 
that  it  requires  forceps  to  remove  it,  or  free  rubbing  with  a  firm 
cotton-wool  brush  ;  but  as  these  proceedings  are  likely  to  lead  to 
haemorrhage,  and  possibly  to  erosions  or  ulcerations,  it  is  better  to 
soften  the  vesicated  coating  by  emollient  sprays  when  it  is  desired 
to  clear  it  away.    When  this  dryness  exists,  fcetor  of  expired 
breath  is  usually  noticed.    This  symptom  is  more  especially  to  be 
observed  when  the  atrophy  extends  to  the  naso-pharynx ;  and  the 
cause  of  the  fcetor  is  not,  as  was  formerly  supposed,  due  to  ulcera- 
tion or  to  bone-disease,  but  to  putrescence  of  the  retained  mucus. 
In  many  cases  of  pharyngitis  sicca  not  extending  to  thenares,  there 
is  no  mal-odour  of  the  breath.    Quite  independently  of  any  of 
these  explanations  of  the  mode  in  which  dry  throat  occurs,  it  may  be 
laid  down  almost  as  an  axiom  that  a  patient  who  awakes  in  the 
night  with  dryness  of  tongue,  mouth  or  throat,  is  the  subject  of  a 


DISEASES  OF  THE  THROAT  AND  NOSE. 


temporary  or  chronic  obstruction  of  the  nares,  and  that  the  dis- 
comfort is  due  to  open-mouth  breathing. 

C.  Miscellaneous. — The  digestive  system  is  always  dis- 
ordered. In  numbers  of  cases,  disturbance  of  the  portal  circu- 
lation, which  is  an  exciting  cause,  is  increased  with  the  advance 
of  the  disease.  Dyspepsia,  which  is  so  frequent  an  accompani- 
ment of  pharyngeal  disorders,  is  in  most  cases  a  result  rather  than 
a  cause.  It  is  probably  due  to  constant  deglutition  of  disordered 
mucus  favouring  the  accumulation  of  flatus  in  the  stomach.  But 
it  is  likely  also  that  the  connection  of  the  glosso-pharyngeal  nerve 
with  the  vagus  may  in  some  measure  account  for  the  gastric 
derangement.  Pain  and  fatigue  in  breath-taking  would  also  be 
thus  explained,  while  irritation  of  the  superior  laryngeal  nerve 
would  account  for  inability  to  produce  high  notes,  and  for  the 
inequality  and  impurity  of  tone  experienced  in  this  condition  inde- 
pendently of  congestion  of  the  larynx.  There  is  sometimes  a 
concurrent  chronic  laryngitis,  but  in  the  majority  of  cases  laryn- 
geal congestion  does  not  extend  to  the  covering  of  the  vocal  cords 
or  ventricular  bands. 

Prognosis  depends  first  on  a  correct  recognition  of  the  cause  by 
the  physician  and  on  prompt  treatment ;  secondly,  on  the  deter- 
mination of  the  patient  to  follow  out  directions  as  to  its  prevention 
when  a  cure  by  suitable  therapeutics  has  been  established.  This 
last  is  happily  not  difficult,  though  the  course  of  treatment  is 
often  tedious. 

Treatment  :  Constitutional. — Encouragement  to  free  secre- 
tion from  the  alimentary  canal  by  mild  saline  purgatives,  such  as 
Friedrichshalle  Bitter  Wasser,  Hunyadi-Janos,  or  Pullna  water, 
will  be  found  of  great  value.  Iron  and  vegetable  tonics  are  of 
use,  and  may  be  advantageously  combined  with  aperients  (Form. 
95,  g6,  97,  lOO,  and  loi).  A  course  of  arsenical  waters  will  in 
many  cases  be  beneficial,  especially  those  of  Bourboule,  by  Mont 
Dore,  which  was  first  uiougiit  under  notice  and  prescribed  in 
England  by  the  author  very  many  years  ago. 

Local. — The  topical  application  of  astringents  and  the  use  of 
astringent  or  expectorant  lozenges  is  often  of  service  where  the 
congestion  is  but  slight  (Form.  12,  16,  17,  and  18),  but  when  there 
is  capillary  engorgement  with  granulations  I  have  seldom  found 
such  measures  sufficient  for  the  purpose,  unless  preceded  by  de- 
struction of  the  enlarged  vessels  which  supply  blood  to  the  hyper- 
trophied  lymphoid  glandules,  these  constituting  the  so-called  granu- 
lations. On  these  vessels  being  divided  and  obliterated  by  means 
of  a  fine  galvano-cautery  point,  the  prominences  will  be  seen  within 


CHRONIC  PHARYNGITIS. 


199 


a  very  short  time  to  shrivel  up  and  disappear.  In  obstinate  cases 
it  is  necessary  to  scrape  the  granulations  with  a  curette.  Where 
the  galvano-cautery  is  not  available,  the  same  end  may  be  obtained 
by  incising  the  vein  transversely  with  a  long-pointed  knife  or 
lancet,  and  then  applying  a  line  caustic  point,  with  a  little 
pressure,  to  the  cut  spot.  When  there  exist  bands  of  inflam- 
matory hypertrophy,  light  scoring  with  the  galvano-cautery  point 
will  bring  about  their  reduction.  Thermal  cautery  by  the  Paquelin 
process,  or  by  wires  heated  in  the  fire,  is  a  very  inferior  method 
to  the  galvanic,  irritation  spreading  further  beyond  the  point  of 
application,  and  the  eschar  being  altogether  more  *  angry,'  and 
less  healthy  in  character.  Many  laryngologists  advise  destruc- 
tion of  the  granules  by  caustic  pastes  (Mackenzie),  by  cautery 
wires  (Michel),  by  blunt  cautery-knives  (Reisenfeld).  Such  a 
plan  does,  however,  but  treat  an  induced  effect,  and  cannot  remove 
the  local  pathological  cause.  Among  topical  applications  recom- 
mended by  various  authors  are  nitrate  of  silver,  chloride  of  zinc, 
sulphate  of  copper,  perchloride  of  iron,  etc.  (Form.  60,  65,  61, 
and  62).  Pharyngeal  sprays  of  the  same  character  may  also  be 
employed  in  mild  cases,  the  strength  of  the  solution  being  not 
more  than  a  fifth  of  that  employed  with  the  brush  (Form.  47). 
Simple  alkaline  or  emollient  applications  are  to  be  preferred  to 
mineral  astringents;  and  in  many  cases  great  relief  to  the 
symptoms  and  benefit  to  the  diseased  condition  is  afforded  by 
sprays  of  cold  water. 

For  impairment  of  the  hearing,  application  of  the  air-douche 
by  catheter  or  Politzer  bag  will  usually  be  found  effectual  in 
clearing  away  secretion  and  maintaining  patency  of  the  Eustachian 
tubes.  When,  however,  there  is  co-existent  disease  in  the  naso- 
pharynx, or  a  congestion  or  thickening  of  the  coverings  of  the 
turbinated  bones,  or  nasal  spurs  leading  to  nasal  stenosis,  local 
treatment  in  the  naso-pharyngeal  and  nasal  passages  is  called  for. 
These  points  will  receive  fuller  consideration  in  the  chapters 
devoted  to  nasal  affections. 

In  very  many  cases,  relaxation  of  the  uvula,  brought  about  by 
the  same  causes  as  the  complaint  of  which  such  a  condition  is 
but  a  symptom,  will  continue  to  keep  up  or  to  re-induce  local  irri- 
tation, and  must  then  be  effectually  treated.  This  subject  will 
be  considered  under  the  special  heading  of  affections  of  the 
uvula. 

Hygiene. — The  principal  injunction  is  to  point  out  how  to  avoid 
recurrence.  Naturally  the  first  indication  is  to  establish  actually 
free  nasal  respiration  ;  and  employment  during  sleep  of  a  '  contra- 


200 


DISEASES  OF  THE  THROAT  AND  NOSE. 


respirator,'  or  other  apparatus  for  keeping  the  mouth  closed,  a 
measure  warmly  advocated  by  Professor  Guye  of  Amsterdam, 
will  often  be  necessary  to  overcome  the  habit  of  mouth-breathing 
at  nights,  even  after  the  nasal  obstruction  has  been  removed. 
Those  who  have  over-used  or  abused  the  voice  must  be  com- 
pelled to  give  it  rest  for  a  time,  and  should  be  warned  that  un- 
less they  desist  from  its  exercise  under  unfavourable  conditions, 
a  relapse  is  certain  to  occur.  A  few  simple  lessons  in  the  first 
principles  of  respiration  in  relation  to  elocution  are  often  most 
necessary.  The  use  of  alcoholic  stimulants  and  tobacco  should  be 
interdicted,  as  well  as  the  taking  of  condiments,  hot  spices,  etc. 
Any  coexisting  diathesis,  as  the  darthous,  herpetic,  scrofulous  or 
tuberculous,  must  receive  its  appropriate  treatment,  and  a  course 
of  waters  at  Vichy,  Mont  Dore,  Cauterets,  or  Aix-les-Bains, 
according  to  the  constitutional  condition,  may  greatly  assist  in 
consolidating  a  cure.  In  some  subjects,  in  whom  the  catarrhal 
influence  is  strong,  it  may  even  be  advisable  to  recommend  the 
patient  to  pass  a  winter  or  two  in  the  South  of  France,  Italy, 
Algiers,  or  Egypt  It  is  necessary,  however,  to  insist  with  Mandl 
that  such  measures  are  only  useful  when  *  not  only  the  inflam- 
matory phenomena  but  also  the  granulations  have  dis- 
appeared.' 

ULCERATION  OF  THE  PHARYNX. 

Ulceration  of  the  pharynx  seldom  occurs  as  the  result  of  a 
simple  angina.  It  is  found,  however,  as  a  sequel  of  the  form  of 
phar3mgeal  inflammation  known  as  hospital  sore-throat,  or  as  the 
result  of  a  specific  dyscrasia,  such  as  syphilis,  scrofula,  cancer, 
tuberculosis,  lupus,  or  lepra,  these  causes  occurring  in  the  frequency 
in  which  they  are  here  enumerated.  Finally  ulceration  may  be 
the  sequel  of  wounds  from  sharp-pointed  foreign  bodies,  which 
have  become  accidentally  lodged  in  some  portion  of  the  tract, 
or  from  corrosive  poiso.is,  scalding  fluids,  etc.,  accidentally 
swallowed. 

PRIMARY  SYPHILIS  OF  THE  PHARYNX. 

This  is  very  rare,  though  buccal  and  faucial  chancres  are  not 
so  uncommon.  A  few  cases  have  been  reported  of  primary 
sores  in  one  or  other  of  the  tonsils,  and  fewer  still  behind  the 
anterior  faucial  pillars,  though  ^^Krishaber  has  mentioned  an 
instance  of  a  chancre  on  the  lingual  surface  of  the  epiglottis.  It 
is  stated  that  the  sores  are  hard  when  on  the  lip  or  buccal  lining, 


SECONDARY  SYPHILIS  OF  THE  PHARYNX. 


201 


soft  on  the  tonsil — a  dictum  not  quite  consonant  with  modern 
views  of  duahty.  The  etiology  is  that  of  direct  contact  with  a 
primary  sore  of  the  part  on  which  the  chancre  is  situated. 
Diagnosis  is  not  often  difficult  if  the  practitioner's  attention  is 
drawn  to  the  local  lesion  before  the  manifestation  of  constitutional 
symptoms.  The  only  diseases  for  which  it  might  be  mistaken 
are  tubercle  and  epithelioma.  Treatment,  which  must  be  directed 
on  general  surgical  principles  not  necessary  to  here  detail,  will 
generally  clear  up  doubts  that  may  arise  as  to  the  nature  of  the 
ulceration. 

SYPHILITIC  ULCERATION  OF  THE  PHARYNX:  SECONDARY 
SYPHILIS  (Figs.  20,  21,  22  and  23,  Plate  III.). 

The  affection  of  the  pharynx  occurring  during  that  stage  of 
syphilis  known  as  the  secondary — that  is  to  say,  in  a  period 
embracing  about  a  year  after  exposure  to  the  primary  infection — 
is  not  really  an  ulceration  at  all,  though  there  may  be,  and  often 
is,  erosion  of  the  mucous  membrane.  The  condition  is  looked  on 
by  nearly  all  writers  as  a  manifestation  of  constitutional  disease ; 
but  Kaposi  states  that  the  papule  and  the  broad  condylomata 
may  convey  contagion,  reproduce  their  kind,  and  in  the  infected 
individual  be  followed  by  secondary  symptoms.  He  believes  that 
in  this  manner  children  often  become  tainted  through  suckling 
from  nurses  who  have  a  papular  syphilide  upon  the  mamma,  and 
that  when  thus  acquired,  the  affection  of  the  infant  is  often 
mistaken  for  hereditary  disease.    I  have  recently  seen  such  a 

manifestation  in  the  fauces  of  an  adult 
patient  who  had  not  contracted  primary 
syphilis  in  coitiiy  but  acknowledged  to 
have  absorbed  the  poison  by  direct  con- 
tact of  the  lips  with  the  vulva  of  an  in- 
fected person.  He  states  that  he  has 
not,  to  his  knowledge,  had  a  primary 
sore. 

'  In  former  editions  I  have  also  reported  the  case  of 
Fig.  CIV.  —  Simt-lation  of  a  single  lady  believed  to  be  the  subject  of  mucous 

^hTfaucIs.  P^!'^'''  '\  ^possible  to  suppose  any 

existence  of  acquired  cause.  Diagnosis  was  made 
solely  on  the  objective  evidences  in  the  throat  (Fig.  CIV.),  and  was  confirmed  by  Dn 
Lefferts,  of  New  York,  and  by  Mr.  Jonathan  Hutchinson  ;  but,  over  five  years  subse- 
quently, the  latter  surgeon  informed  me  that  there  is  the  strongest  reason  to  believe  that 
the  condition  has  been  induced  and  kept  up  factitiously.' 

The  secondary  manifestation  of  syphilis  in  the  pharynx  is 


202  DISEASES  OF  THE  THROAT  AND  AOSE. 


characterized  by  the  presence  of  symmetrical  congestive  patches 
(erythema),  submucous  infiltration,  and  mucous  tubercles,  followed 
by  exudation  in  the  form  of  plaques,  or  by  formation  of  condylo- 
mata, on  the  pillars  of  the  fauces,  tonsils,  velum,  and  uvula,  as 
well  as  on  the  lining  of  the  buccal  cavity,  and  on  the  edges  and 
tip  of  the  tongue.  The  disease  may  extend  from  the  fauces 
and  naso-pharynx  to  the  Eustachian  tube,  and  may  also  be 
present  in  the  anterior  nares ;  but  it  seldom  attacks  the  posterior 
pharyngeal  wall. 

These  plaques  appear  in  the  pharynx — itself  of  normal  hue,  or 
but  slightly  congested  and  swollen — as  bright  red  crescentic  or 
circular  blushes,  in  the  centre  of  which  may  be  seen  a  white 
opaline  spot,  with  an  appearance  very  like  that  presented  by  what 
artists  call  *  glazing.'  As  the  disease  advances,  this  opaline 
glazing  becomes  thicker  and  greyer,  and  its  surface  looks  as  if  in 
folds.  When  appearing  on  the  tonsils,  the  characteristics  of  the 
plaques  are  less  marked,  as  these  glands  become  simultaneously 
hypertrophied  and  inflamed,  and  the  products  of  their  secretion, 
whitish-grey  in  colour,  may  cause  some  confusion.  If  the  dis- 
ordered epithelial  covering  of  these  plaques  becomes  detached, 
superficial  vertical  cracks  or  erosions  can  be  noticed. 

The  SUBJECTIVE  SYMPTOMS  of  Secondary  syphilis  of  the  pharynx 
are  often  not  well  marked,  and  differ  but  Httle  from  that  of  a 
common  sore  throat.  The  principal  sensation  is  an  irritation 
and  some  pain  in  swallowing,  this  last  sign  varying  greatly  in 
different  individuals. 

Objective  Symptoms. — The  strong  diagnostic  point  in  second- 
ary syphilitic  manifestations  in  the  pharynx  consists  in  the  local 
evidence  of  the  disease.  This  is  characterized  by  symmetry  of 
the  erythematous  or  mucous  patches ;  not  the  symmetry  of 
I'^Moxon,  arising  from  the  fact  that  the  throat,  in  common  with 
the  rest  of  the  body,  is  com.posed  of  two  symmetrical  halves,  but 
in  many  cases  by  the  veritable  *  Dutch  garden  symmetry,'  re- 
ferred to  by  ^^Jonathan  Hutchinson.  This  is  well  illustrated  in  all 
the  figures  of  this  disease  in  Plate  III. ;  especially  in  the  first  and 
fourth  (20  and  23),  where  it  will  be  seen  that  even  on  the  uvula 
the  patches  are  almost  geometrical  in  symmetry  ;  and  such  illus- 
trations are,  indeed,  not  uncommon,  but  typical. 

A  peculiarity  of  this  disease,  when  seen  very  early  in  its  course, 
is  that  the  congestion,  or  at  any  rate  som.e  part  of  it,  is  masked, 
as  it  were,  so  that  on  first  view  of  the  throat  the  surgeon  may  be 
in  doubt  as  to  its  specific  nature     If,  however,  the  throat  be  a 


SECONDARY  SYPHILIS  OF  THE  PHARYNX.  203 

little  irritated  by  the  finger,  or  with  a  brush,  the  distinctive 
character  will  at  once  be  intensified,  much  in  the  same  way  as  a 
skin-rash  under  similar  circumstances  will  be  more  readily  diag- 
nosed by  slight  surface-friction. 

The  history  of  the  case,  and  the  co-existence  of  a  squamous  or 
roseolous  eruption  on  the  skin,  will  confirm  the  diagnosis.  There 
is  not  unfrequently  considerable  rise  of  temperature  on  the  first 
approach  of  this  form  of  sore  throat. 

The  usual  period  of  the  first  appearance  of  these  secondary 
manifestations  is  from  six  weeks  to  six  months  after  the  primary 
contagion. 

Prognosis  is  always  favourable  if  the  patient  can  be  induced  to 
persevere  with  treatment.  The  only  compHcation  of  a  serious 
character  is  extension  of  the  disease  to  the  larynx,  which  leads  to 
a  very  troublesome  form  of  inflammation  with  marked  and  obsti- 
nate huskiness  of  voice. 

Treatment  :  Constitutional. — Some  authorities  are  of  opinion 
that  the  cases  of  syphilis  in  which  the  secondary  manifestations 
are  most  severe  are  least  prone  to  suffer  from  later  ravages.  As 
far  as  the  throat  is  concerned,  there  can  be  but  little  doubt  that 
this  later  immunity  is  in  proportion  to  the  efficacy  and  persistence 
of  treatment  during  the  earlier  stages  of  the  disease.  Especially 
is  this  the  case  if  a  mild  mercurial  course,  never  reaching  to  the 
verge  of  salivation,  is  pursued  concurrently  with  local  measures. 
The  tendency  to  salivation  is  much  diminished  if  the  patient  is 
directed  to  carefully  cleanse  his  teeth  with  more  than  usual 
vigilance,  and  especially  after  each  meal,  and  if  he  use  freely  a  deter- 
gent mouth-wash  or  gargle  (Form.  2,  6,  8,  10,  and  11).  Chlorate 
of  potash  has  proved  superior  in  our  practice  to  the  solutions  of 
alumina,  in  favour  at  Aix-la-Chapelle  ;  and  thorough  cleansing  of 
the  teeth  with  a  soft  brush  is  insisted  on  by  me  as  an  important 
preventive  of  extension  of  the  disease  by  local  irritation.  My 
favourite  form  for  the  administration  of  mercury  at  this  stage 
of  syphilis  is  in  five-grain  doses  of  the  compound  calomel,  or 
Plummer's  pill,  twice  or  thrice  daily.  For  some  time  past  I  have 
administered  this  combination  of  mercury  in  an  effervescing 
lozenge,  each  one  of  which  contains  the  ingredients  of  a  five- 
grain  pill  (Form.  13).  In  obstinate  cases  inunction  should  be 
employed.  In  this  view  as  to  the  importance  of  mercurial  treat- 
ment I  am  supported  by  most  syphilographers ;  and  ^^Morell- 
Mackenzie  probably  stands  alone  among  the  throat-specialists  in 
nonsidering  that  '  secondary  syphilitic  affections  of  the  pharynx 


204  DISEASES  OF  THE  THROAT  AND  NOSE, 


do  not  usually  require  any  constitutional  remedies.'  There  is,  tc 
say  the  least  of  it,  an  incompleteness  in  his  argument  *  that  the 
non-use  of  mercury  does  not  increase  the  risk  of  a  further 
development  of  the  disease,'  because  *  he  has  rarely  met  with 
tertiary  phenomena  in  the  throat  among  those  whom  he  previously 
treated  for  the  earher  manifestations'  by  *  local  remedies'  and 
without  *  any  specific  treatment.'  It  only  remains  to  be  added 
that  in  very  rare  instances  mercury  is  not  well  borne.  Where 
this  is  the  case,  the  patient  is  generally  possessed  of  a  scrofulous 
or  tuberculous  taint,  and  iodides  of  iron  or  of  sodium,  with  cod- 
liver  oil,  will  be  preferably  indicated. 

Local. — This  consists  essentially  in  frequent  caustic  or  resolvent 
applications,  limited  to  the  exact  area  of  each  patch  of  erosion  or 
mucous  deposit.  In  some  cases  iodine  is  of  service,  in  others 
sulphate  of  copper  is  efficient.  Iodoform  has  also  been  recom- 
mended, but  offers  no  superior  advantage  over  other  applications 
sufficient  to  counteract  its  nauseative  effects  and  disagreeable 
odour ;  it  is  now  substituted  in  our  practice  by  lodol,  which  is 
similar  in  constitution,  and  though  less  powerful  is  inodorous. 
My  own  experience  leads  me  to  rely  almost  solely  on  the  daily 
use  of  nitrate  of  silver  in  the  solid  form,  applied  accurately  to 
each  diseased  patch.  Even  after  all  spots  are  healed,  the  patient 
should  be  carefully  examined  once  or  twice  a  week,  and  be 
treated  with  renewed  energy  on  recurrence  of  the  sHghtest 
relapse.  Where  there  are  cracks  or  erosions,  and  in  the  some- 
what rare  cases  in  which  pain  accompanies  a  *  secondary '  sore 
throat,  I  have  usefully  substituted  iodine  and  carbolic  acid 
(Form.  63)  as  a  local  pigment.  Where  there  is  pain  from  ex- 
tension to  the  ear,  with  deafness,  inhalations  (Form.  30,  31 
and  32),  used  as  described  at  page  104,  are  beneficial ;  when  the 
mucus  in  the  nares  is  apt  to  become  inspissated,  emollient  appli- 
cations (Form.  82  and  84)  and  nasal  douches  may  be  called  for 
(Form.  73,  74,  75,  76,  77,  and  78). 

It  is  important  to  note  that  operations,  such  as  excision  of  an 
enlarged  tonsil,  or  ablation  of  an  elongated  uvula,  should  not  be 
performed  during  the  course  of  secondary  manifestations  in  this 
region,  since  the  raw  surface  is  almost  sure  to  take  on  afresh  the 
diseased  condition. 

Dietary  and  Hygienic. — The  diet  must  be  non-irritant,  and, 
both  on  general  and  local  grounds,  influences  calculated  to  induce 
catarrh  must  be  guarded  against.  Warm  baths,  with  free  use  of 
soap,  and  Turkish  baths  are  useful  aids  towards  elimination  of 


TERTIARY  SYPHILIS  OF  THE  PHARYNX. 


205 


the  poison.  Smoking  should  ahvays  be  interdicted.  Too  much 
care  cannot  be  enjoined  against  the  possibihty  of  communicating 
the  contagion  to  others. 

TERTIARY  SYPHILIS  (Figs.  24,  25,  and  26,  Plate  III. ;  Fig.  17,  Plate  11. ; 
Figs.  39  and  40,  Plate  V. ;  and  Figs.  109  and  no,  Plate  XIII.) 

The  tertiary  form  of  syphihs,  which  occurs  in  the  pharynx  at 
a  period  of  from  two  to  five  years  up  to  any  length  of  time  after 
primary  infection,  is  characterized  by  true  ulceration  or  loss  of 
tissue,  and  is,  according  to  modern  views,  always  the  result  of 
degeneration  of  gummatous  deposit.  The  ulceration  may  be, 
and  often  is,  confined  to  one  spot,  or  there  may  be  several  ulcers 
concurrently  (Fig.  CV.,  and  Fig.  no,  Plate  XIII.).    In  the 

earlier  stages,  ulceration  is 
generally  confined  to  the 
pillars  of  the  fauces,  espe- 
cially at  their  junction  with 
the  tongue,  to  the  uvula, 
and  particularly  to  the  velum. 

This  last-named  part,  be- 
ing of  soft,  loose  structure, 
and  bounded  on  both  sides 
by  mucous  membrane,  offers 
little  resistance  to  its  de- 
structive changes,  and  yields 
rapidly  to  the  inroads  of  the 
disease.  In  this  situation, 
a  red  boggy  patch  is  often 
seen  on  the  buccal  surface,  which  will,  if  unchecked,  speedily  lead 
to  perforation.  In  such  a  case  the  ulceration  has  commenced  on 
the  posterior  surface  of  the  soft  palate,  and  may  often  be  seen 
and  treated  with  the  rhinoscope  before  perforation  has  taken 
place  (Fig.  40,  Plate  V.).  Ulceration  also  occurs,  generally  in 
the  median  line,  either  at  the  junction  of  the  soft  and  hard  palate, 
or  over  the  hard  palate  itself,  and  may  also  often  be  found  just 
behind  the  upper  incisor  teeth. 

The  accompanying  drawing — Fig.  CVI.  (see  also  Fig.  109,  Plate  XIII.)— represents 
a  central  perforation,  the  result  of  recrudescence  of  specific  inflammation,  and  was  taken 
in  February,  1879,  from  the  throat  of  a  patient,  aged  twenty-five,  who  had  been  formerly 
a  private  in  the  Grenadier  Guards,  and  had  contracted  primary  syphilis  five  years  previous 
to  coming  under  my  notice.  In  the  latter  part  of  1877  his  palate  and  nasal  bones  became 
diseased,  and  '  eleven  separate  pieces  of  bone  '  had  been  extruded.  His  present  attack 
had  existed  for  five  weeks  before  his  visit.  There  was  but  slight  facial  deformity,  but 
the  nostrils  which  communicated  with  the  palatal  opening  were  ulcerated,  and  roughened 
bone  could  be  felt  with  the  probe. 


Fig.  CV.  Tertiary  Ulceration  of  Soft 

Palate  and  Pharyngeal  Wall  ;  Per- 
foration OF  Right  Faucial  Pillar. 


200 


DISEASES  OF  THE  THROAT  AND  NOSE. 


It  is  seldom  that  the  posterior  wall  of  the  pharynx  is  attacked  by 
ulceration  earlier  than  five  years  after  the  first  infection  ;  but  I  have 
seen  a  few  cases  in  which  the  primary  infection  had  occurred  less 
than  three  years  previ- 
ously. "When  the  ulcer 
has  once  formed,  it  spreads 
rapidly,  and  its  secretion, 
composed  chiefly  of  epi- 
thehal  detritus  and  pus 
cells,  contains  highly  septic 
properties.  The  edges  of 
the  ulcers,  be  they  round 
or  irregular,  are  bounded 
by  a  deep -red  halo,  pro- 
bably caused  by  the  escape 
of  colouring  matter  of  the 
blood  from  compression  of  ^ig.  CVI.-Tertiary  Syphilis  ;  Central  Per- 

^  FORATION  OF  HaRD  AND  SOFT  PaLATE.  (See 

the  vessels  by  cell-mfiltra-      also  Fig.  109,  Plate  XIII.) 
tion.   When  the  tongue  is 

ulcerated,  it  is  usually  in  the  median  line,  or  as  longitudinal  fissures. 
As  the  ulcers  heal,  the  surface  assumes  a  peculiar  bluish  glazed 
appearance  (Fig.  26,  Plate  III.).  In  both  secondary  and  tertiary 
syphiHs  a  complaint  is  often  made  that  the  tongue  feels  too  large 
for  the  mouth,  and  on  examination  this  organ  will  be  frequently 
seen  indented  by  the  teeth.  Ulcerations  of  the  edges  of  the  tongue 
are  often  excited  by  irritation  of  decayed  stumps  of  the  teeth. 

The  SUBJECTIVE  SYMPTOMS  of  this  disease  are  frequently  not 
very  well  marked  when  the  pillars  of  the  fauces  only  are  involved, 
since  pain,  at  least  in  any  proportion  to  the  mischief,  is  but 
seldom  experienced  ;  when,  however,  there  is  perforation  of  the 
palate,  or  the  velum  or  uvula  sloughs  away,  a  characteristic  result 
is  impairment  of  voice.  This  is  due  to  loss  of  power  to  shut  off 
the  mouth  from  the  naso-pharynx  during  articulation.  From  the 
same  cause  the  greatest  inconvenience  is  experienced  in  swallow- 
ing fluids,  which  pass  into  the  nasal  cavity  and  are  ejected  by  the 
nostrils.  When  the  posterior  wall  of  the  pharynx  is  attacked, 
the  ulceration  may  commit  most  fearful  ravages,  extending  up- 
wards into  the  nares  and  downwards  to  the  epiglottis.  It  may 
be  noted,  however,  that  syphilitic  ulceration  of  the  larynx,  except 
of  the  epiglottis,  occurs  at  a  much  later  period  than  in  the 
pharynx. 

Diagnosis. — The  history  of  the  case,  the  post-cervicai  glandular 
enlargement,  absence  of  sympathetic  induration  of  the  parotid. 


TERTIARY  SYPHILIS  OF  THE  PHARYNX,  207 

submaxillary  or  anterior  cervical  glands,  the  comparative  freedom 
from  pain,  and  above  all,  its  amenity  to  appropriate  remedies, 
will  distinguish  this  disease  from  cancer,  the  only  malady  with 
which  it  is  likely  to  be  confounded. 

Prognosis. — This  is  almost  invariably  favourable  under  suit- 
able treatment,  although  the  patient  may  have  been  reduced,  as 
often  happens,  to  extreme  emaciation.  A  co-existent  scrofulous 
diathesis  is,  however,  most  obnoxious  to  the  success  of  remedial 
efforts.  The  danger  of  hgemorrhages  and  necroses  of  bone  in 
the  acute  stage,  and  of  cicatrization,  leading  to  adhesions  and 
stenoses,  as  sequelae,  must  not  be  forgotten  when  forming  a 
prognosis.  These  adhesions  sometimes  give  rise  to  very  grotesque 
appearances,  one  of  which  is  illustrated  in  the  accompanying 
figures.  Another  may  be  seen  in  the  coloured  Plate  II.,  Fig.  17. 

Treatment:  Constitutional— This  will  consist  in  the  ad- 
ministration of  iodide  of  potassium  in  3-grain  to  lo-grain  doses 
during  active  ulceration.  Some  patients  are  peculiarly  susceptible 
to  the  action  of  iodine  when  combined  with  potassium.  It  has, 
however,  been  noticed,  I  think,  by  Mr.  Hutchinson,  that  where 
this  is  so,  the  desired  effect  is  obtained  with  very  small  doses  of  the 
drug.  If  in  such  cases  the  tendency  to  coryza  be  not  counteracted 
by  the  addition  of  ammonia  or  of  tincture  of  nux  vomica,  iodide  of 
sodium  should  be  substituted.  The  atomic  weight  of  sodium 
being  less  than  that  of  potassium,  a  smaller  dose  of  the  former 
may  be  administered.  Certainly  all  soda  salts  are  less  depress- 
ing than  those  of  potash.  When  the  acute  attack  is  past,  the 
prolonged  exhibition  of  perchloride,  biniodide,  proto-iodide,  or 
bicyanide  of  mercury,  in  small  doses,  is  all-important  as  a  tonic, 
and  as  a  prophylactic  against  future  relapses  (Form.  91,  92,  104, 
and  105). 

Local. — Until  ten  years  ago  I  was  in  the  habit  of  treating  all 
these  tertiary  ulcerations  by  the  daily  local  application  of  nitrate 
of  silver,  of  acid  nitrate,  or  cyanide  of  mercury,  or  of  sulphate 
of  copper,  the  first-named  being  preferred ;  and  such  a  plan  I 
would  still  recommend  under  the  ordinarily  available  opportunities 
of  general  practice.  I  have,  however,  met  with  such  marked 
success,  both  as  to  rapidity  of  cure  and  freedom  from  recurrence, 
from  the  employment  of  the  galvano-cautery,  that  this  measure 
has  largely  superseded  the  use  of  the  mineral  caustics  in  my 
practice. 

Whatever  application  be  made,  care  must  be  taken  to  thoroughly 
cleanse  the  part  of  all  coating  of  secretion  over  the  ulcerations 
before  the  local  remedy  be  applied. 


2o8 


DISEASES  OF  THE  THROAT  AND  NOSE, 


Gargles  of  permanganate  of  potash,  chlorate  of  potash,  and 
carbolic  acid,  all  aid  in  keeping  the  mouth  free  from  accumula- 
tion of  muco-purulent  deposit  (Form.  2,  8,  9,  and  10).  Ice  is  also 
frequently  most  grateful. 

Local  treatment  must  be  pursued  with  the  same  constancy  and 
persistence  as  in  the  secondary  form  of  the  disease,  and  success 
in  these  cases  depends  as  much  on  the  perseverance  of  the  patient 
as  on  the  energy  of  the  medical  attendant. 

Dietary. — Pain  in  deglutition  is  not  usually  a  prominent  symptom 
in  tertiary  syphilis  as  affecting  the  pharynx.  Many  patients,  there- 
fore, while  requiring  to  take  food  of  a  semi-solid  character,  or,  in 
cases  of  perforation  of  the  palate,  liquids  previously  thickened, 
need  not,  as  a  rule,  be  restricted  in  their  dietary,  except  so  far  as 
the  general  prohibition  of  condiments  and  of  fluids  at  high  tem- 
perature (so  frequently  insisted  upon  in  these  pages),  extends. 


Figs.  CVII.  and  CVIIL— AdhesiOxV  of  Uvula  to  Faucial  Pillars,  showing. 
Difference  of  Appearance  in  State  of  Repose  and  of  Contraction  on 
Inspiration.  A  fresh  Ulcer  can  be  observed  in  the  Situation  of  Left 
Tonsil. 

It  is  to  be  remembered  that  in  the  healing  of  these  pharyngeal 
ulcerations,  cicatrization,  with  much  plastic  exudation,  is  occa- 
sionally followed  by  contraction  and  constriction  of  the  pharynx^ 
for  the  dilatation  of  which  mechanical  or  surgical  measures  may 
be  advisable.  And  on  this  account  it  may  be  noted  that  no 
morsel  of  tissue,  seem  it  to  be  ever  so  lightly  attached,  should  be 
separated  by  the  knife  ;  for  it  is  impossible  to  say  how  useful  this 
small  atom  may  be,  as  a  starting-point  for  healthy  action,  when 
the  reparative  process  is  once  set  up. 

Whenever  cicatrization,  leading  to  adhesion  of  the  soft  palate  to 
the  wall  of  the  pharynx  or  to  one  side  or  other  of  the  fauces  (Figs. 
CVII.  and  CVIIL),  takes  place,  nasal  respiration  is  obstructed,  the 
sense  of  smell  is  impaired,  the  patient  experiences  great  difficulty 
in  clearing  the  nasal  passages,  and  the  disagreeable  tone  of  voice 
is  but  too  frequently  a  permanent  witness  of  his  malady. 


CONGENITAL  SYPHILIS  OF  THE  PHARYNX. 


log 


In  some  instances  fragments  saved  from  the  destructive 
ulceration,  becoming  hypertrophied  and  separated,  appear  as 
distinct  new  growths  (Figs.  25  and  26,  Plate  III.;  and  Fig.  17, 
Plate  II.).  When  loss  of  tissue  of  the  palate  has  been  con- 
siderable, it  is  often  necessary  for  the  patient  to  wear  some  form 
of  obturator. 

A  case  was  recently  under  my  notice  and  treatment  at  the  Central  Throat  and  Ear 
Hospital,  in  which  adhesive  contraction  took  place  of  the  tissues  of  the  pharynx,  fauces, 
and  root  of  the  tongue  just  above  the  level  of  the  epiglottis.  This  led  to  an  annular 
stricture,  which  barely  admitted  a  goose  quill.  Some  relief  to  the  consequent  dysphagia 
was  afforded  by  division  with  a  galvano-caustic  knife  and  frequent  passage  of  the  bougie, 
but  the  patient  left  Hospital  before  any  definite  benefit  was  arrived  at. 

In  all  cases  where  the  ulceration  is  healed,  a  more  or  less  distinct 
and  permanent  stellate  cicatrix  is  formed  (shown  in  Figs.  17  and 
25,  Plate  II.),  which  often  proves  of  great  diagnostic  importance 
in  the  later  history  of  those  cases  in  which  doubt  might  arise  as 
to  the  nature  of  laryngeal  mischief.  The  same  may  be  said  of 
any  perforations  (Fig.  26)  that  remain  unhealed. 

CONGENITAL  AND  HEREDITARY  SYPHILITIC  ULCERATION 
OF  PHARYNX  (Fig.  27,  Plate  III.). 

This  affection  may  make  itself  evident  at  a  very  early  date 
after  birth,  and  is  usually  manifested  before  the  period  of  puberty. 

^^John  N.  Mackenzie,  in  a  valuable  paper  on  this  hitherto 
almost  unexplored  subject,  states  that  nearly  50  per  cent,  of  the 
cases  occur  within  the  first  year  of  life,  and  as  many  as  33  per 
cent,  within  the  first  six  months. 

I  have  myself  witnessed  cases  in  adults,  and  indeed  at  almost 
all  periods  of  life  ;  but  I  have  rarely  seen  a  case  in  which  there 
were  symmetrical  mucous  patches  in  the  pharynx  of  a  congenital 
syphilitic  patient,  that  stage  having  probably  been  reached  and 
passed  during  intra-uterine  life.  The  condition  of  the  pharynx, 
as  I  have  witnessed  it,  has  more  frequently,  even  at  quite  early 
periods  after  birth,  been  one  of  true  ulceration ;  though  I  admit  to 
having  witnessed,  in  the  same  individuals,  manifestations  in  the 
skin,  cornea,  etc.,  which  were  truly  secondary  in  their  character. 

In  this  experience  as  to  the  occurrence  of  deep  ulceration  at  such 
a  very  early  period  of  life  I  am  supported  by  John  Mackenzie. 
The  ulceration  may,  according  to  this  author,  occur  in  any 
situation ;  but  its  favourite  seat  is  the  palate,  and  especially  the 
hard  palate.  When  it  occurs  upon  the  posterior  aspect  of  the 
latter,  the  tendency  is  to  involve  the  soft  palate  and  velum,  and 
thence  to  invade  the  naso-pharynx  and  posterior  nares.    This  is 

14 


210 


DISEASES  OF  THE  THROAT  AND  NOSE, 


well  seen  in  Fig.  CIX.,  taken  from  a  child  aged  eight.  Seated 
anteriorly,  it  seeks  a  more  direct  pathway  to  the  nose.  The  next 
common  localities  are,  in  order  of  frequency,  the  fauces,  naso- 
pharynx, the  posterior  pharyngeal  wall,  the 
nasal  fossae,  the  septum  nasi,  the  tongue, 
and  finally  the  gums.  A  peculiarity  in 
these  ulcerations  is  their  centrality  of 
position,  and,  furthermore,  their  special 
tendency  to  attack  the  bone  and  to 
eventuate  in  caries  and  necrosis.  The 
ravages  of  the  disease  present  the  typical 
appearances  that  are  found  in  the  tertiary 
syphilis  of  the  adult.  The  oesophagus  is 
but  very  rarely  attacked.  It  is  with  hesi- 
tation that  I  venture  to  differ  from  John 
Mackenzie  on  a  clinical  point  in  connection  with  this  subject,  but 
I  can  hardly  agree  '  that  the  invasion  of  the  larynx  may  be  looked 
for  with  the  same  confidence  in  the  congenital  as  in  the  acquired 
form  of  the  disease.'  It  is  quite  true  that  laryngeal  manifesta- 
tions occur  occasionally  without  evidence  of  pre-existing  pha- 
ryngeal lesions,  but  my  experience  tends  to  the  view  that,  as  a 
rule,  the  ulceration  of  congenital  syphilis  is  limited  to  the 
palato-pharyngeal  and  naso-pharyngeal  tissues,  and  that  laryngeal 
mischief  is  a  comparatively  rare  sequel. 

A  point  of  much  clinical  interest  and  importance  which  has 
occupied  the  attention  of  Continental  syphilographers,  and  has 
been  elucidated  in  its  special  application  to  the  throat,  by  John 
Mackenzie,  is  the  influence  of  some  of  the  ordinary  infectious 
diseases  of  childhood  upon  the  progress  of  the  inherited  syphilitic 
affection.  Sufficient  evidence  has  been  adduced  to  warrant  us  in 
saying  (i)  that  while  congenital  S3^philis  affords  no  absolute  pro- 
tection against  certain  acute  infectious  diseases,  its  existence  in 
the  individual  seems  often,  other  things  being  equal,  to  mitigate 
their  severity  and  exert  a  favourable  influence  on  their  course  ; 
and  (2)  that  certain  acute  diseases,  accompanied  by  an  exanthem — 
as,  for  example,  scarlatina  and  measles — favour  the  dissipation,  at 
least  temporarily,  of  the  pharyngeal  and  other  manifestations  of 
the  disease.  On  the  other  hand,  with  regard  to  diphtheria,  when 
this  affection  supervenes  during  the  existence  of  syphilitic  lesions 
in  the  throat,  the  patient  rapidly  succumbs  to  the  former  disease 
— the  existence  of  the  syphilis  apparently  increasing  the  tendency 
to  membranous  formation. 

Symptoms. — Beyond  the  character  of  the  ulceration,  there  are 


Fig.  CIX.  —  Ulceration 
OF  Wall  of  Pharynx 
AND  OF  Soft  Palate  in 
Hereditary  Syphilis. 


CONGENITAL  SYPHILIS  OF  THE  PHARYNX. 


211 


other  signs  which  make  the  diagnosis  comparatively  easy  in  the 
case  of  infants.  They  are  well  known  to  every  practitioner.  The 
chief  are  :  impediment  to  nasal  respiration  and  inability  to  take 
the  breast ;  with  coryza,  leading  to  excoriations  and  ulcerations 
of  the  skin  and  of  the  alae  of  the  nose  and  the  lips. 

Prognosis  is  greatly  influenced  by  the  age  at  which  the  patient 
is  attacked.  The  earlier  the  manifestation,  the  more  serious  are 
the  results.  Pharyngeal  ulceration  occurring  within  the  first  year 
of  life  is  almost  invariably  fatal.  Most  disfiguring  injuries  to  the 
palate,  nose,  and  skin  are  often  witnessed  in  those  who  survive. 

In  the  majority  of  cases  of  deafness  arising  from  inherited 
■disease,  doubtless  the  affection  frequently  invades  the  internal 
•ear ;  but  experience  would  seem  to  indicate  that  in  many  cases 
of  even  extreme  deafness  coming  on  concurrently  with  pharyngeal 
ulceration,  the  aural  trouble  is  confined  to  the  middle  ear,  and  is 
a  direct  extension  of  the  pharyngeal  mischief,  since  in  such  a  case 
inhalations,  Politzer  inflation,  and  other  remedies  directed  to  the 
tympanic  cavity,  will  cure  the  deafness  when  the  ulcer  is  healed. 
It  is  important  to  remember  this,  since  surgeons  are  too  apt  to 
look  on  all  cases  of  syphilitic  deafness  as  hopeless.  Of  course,  it 
is  quite  possible  that  middle-ear  inflammation  and  cochleitis  may 
co-exist. 

Treatment. — The  general  treatment  must,  as  far  as  circum- 
stances permit,  be  carried  out  upon  the  same  lines  as  recommended 
in  the  acquired  form  of  the  disease.  Remembering,  however,  how 
much  better  children  bear  mercury  than  do  adults,  this  drug  may 
with  advantage  be  administered  with  proportionately  greater 
freedom.  The  best  form  is  that  of  grey  powder.  Moderate  in- 
unction is  also  well  tolerated.  After  the  first  few  years  of  life, 
iodide  of  sodium  with  iodide  of  iron  is  a  most  efficient  remedy. 

I  lay  great  stress  on  local  treatment  in  children,  even  the 
youngest,  by  nasal  douches  administered  twice  or  thrice  a  day, 
and  always  before  attempts  at  suckling,  by  means  of  the  nasal 
syringe  (Fig.  LXXIV.).  The  best  solutions  are  those  of  chlorate 
of  potash,  borax,  etc.  (Form.  73,  and  78).  The  after-application 
of  an  ointment  of  vaseline  and  eucalyptus-oil  (Form.  82),  of  iodol 
/Form.  84),  or  of  boracic  acid  (Form.  81),  with  the  addition  of  red 
oxide  of  mercury  ointment  (i  to  16  parts),  has  in  my  hands  been 
of  more  service  than  swabbing  the  passages  of  the  nose  and 
throat  with  caustics.  In  no  circumstance  do  I  employ  nitrate  of 
silver  in  infants ;  first,  because  I  have  seen  tv/o  cases  in  which  a 
prolonged  course  of  such  applications  has  resulted  in  permanent 
discolouration  of  the  skin,  and  secondly,  because  nitrate  of  silver 


212 


DISEASES  OF  THE  THROAT  AND  NOSE, 


locally  applied  has  a  decided  tendency  to  favour  the  hyperplasia, 
which  is  already  a  sufficiently  marked  sequel  of  all  specific  ulcera- 
tions. In  two  instances  of  threatened  destruction  of  the  nose,  I 
have  seen  the  galvano-cautery  arrest  ulceration,  where  every  other 
measure  appeared  to  be  useless. 

Dietary. — Of  the  greatest  importance  is  the  nourishment  of 
children  who  are  the  subjects  of  syphilis  ;  and  Cohen  urges,  with 
correctness,  that  a  healthy  wet-nurse  should  be  procured,  though 
'  a  syphilitic  wet-nurse  is  admissible,  provided  she  is  placed  under 
specific  treatment — that  is  to  say,  mercurialized.'  If  a  child 
cannot  suckle,  no  time  should  be  lost  in  feeding  it  by  the  spoon, 
care  being  taken  not  to  give  the  milk  of  such  a  strength  as  to 
endanger  assimilation. 

Hygienically,  the  syphilitic  infant  requires  the  greatest  care  in 
the  way  of  warm  baths,  warm  clothing,  etc. 

SCROFULOUS  ULCERATION  OF  THE  PHARYNX  (Fig.  113, 
Plate  XHL). 

Scrofulous  pharyngitis  is  described  by  ^'^Isambert  and  others  as 
a  quite  distinct  form  of  disease  ;  but  I  must  confess  to  having  never 
seen  a  case  in  which  there  were  present  the  symptoms  described 
by  those  authorities,  unless  there  was  a  concurrent  syphilitic  or 
tuberculous  dyscrasia.  Many  so-called  cases  of  scrofula  of  the 
pharynx  are  also  due  to  lupus.  I  am  gratified  to  find  that  this 
disbelief  of  uncomplicated  scrofulous  ulceration,  which  I  expressed 
in  my  first  edition,  is  shared  by  such  accurate  observers  as  Schech, 
E.  Wagner,  and  John  Mackenzie.  The  last  writer  affirms  that 
'  there  is  no  just  ground  for  belief  in  an  ulcerative  scrofulide  of 
the  throat.  It  needs  only  the  most  superficial  review  of  the 
writings  of  those  who  maintain  its  separate  existence  to  show 
the  utter  confusion  which  prevails  as  the  result  of  erroneous 
views,  handed  down  among  the  traditions  of  an  obsolete 
pathology.* 

To  prevent  misunderstanding,  it  may  be  as  well  to  state  that  I 
do  not  deny  a  specific  manifestation  of  scrofula  in  the  phar3'nx  ; 
I  only  affirm  that  it  is  not  usually  one  of  ulceration.  The  form  in 
which  I  have  seen  it  exemplified  is  that  of  a  low  type  of  inflamma- 
tory thickening  of  the  fauces,  of  the  naso-pharyngeal  passages,  of 
the  nasal  septum,  of  the  glands  in  the  vault  of  the  pharynx,  and 
of  the  faucial  tonsils,  accompanied  not  unfrequently  by  a  similar 
condition  of  the  neighbouring  lymphatic  glands,  which  often 
undergo  disintegration.  There  is  also  occasional  necrosis  of  the 
turbinated  bone. 


SCROFULOUS  ULCERATION  OF  THE  PHARYNX.  213 


While  admitting  that  syphilis,  if  transmitted,  must  produce 
syphilis,  it  is  auite  certain  that  this  disease,  when  manifested  in  a 
subject  tainted  wren  scrofula,  has  certain  symptoms  superadded. 
In  such  a  case  the  local  manifestations  appear  to  arise  in  the 
glandules,  which  are  hypertrophied  and  are  hable  to  ulceration. 
The  ulcerations  are  at  the  commencement  superficial  and  indolent, 
but  sooner  or  later  perforation  takes  place,  and  many  characteristics 
of  a  true  syphilitic  ulceration  are  presented,  with  others  super- 
added. When  remedial  measures  are  applied,  it  is  found  that  the 
disease  does  not  respond,  as  might  be  expected,  to  the  remedies 
applicable  to  either  scrofula  or  syphilis  separately.  And  here  I 
may  be  allowed  to  adopt  the  words  of  ^^Sir  James  Paget :  *  I  would 
not  venture  to  call  the  disease  that  may  occur  in  a  scrofulous 
person  become  syphilitic  a  hybrid  one,  and  yet  perhaps  the  term 
is  not  altogether  wrong ;  but  at  least  I  would  call  it  a  mixed  dis- 
ease, and  hold  that  syphilis  inserted  in  a  scrofulous  person  will,  in 
its  tertiary  period,  produce  signs  which  it  may  be  very  hard  to 
distinguish  from  scrofula — signs  in  which  the  characters  of 
scrofula  and  of  syphilis  are  mingled,  and  (which  is  very  important) 
which  require  that  the  treatment  of  scrofula  should  be  combined 
with  the  treatment  of  syphiHs,  in  order  to  produce  a  fully  success- 
ful result' 

A  case  of  this  nature  is  depicted  in  Fig.  113,  Plate  XIII. 

The  drawing  was  taken  from  a  female  patient  infected  when  pregnant  with  her  first 
child  some  five  years  previously.  She  had  had  three  or  four  miscarriages,  but  had  not 
given  birth  to  a  living  child.  She  was  of  a  strongly  marked  strumous  habit,  and  bore 
scars  in  her  neck  of  glandular  abscesses  when  a  child.  The  ulceration  was  markedly 
tuberculated,  and  might  be  considered  as  almost  lupoid.  There  was,  however,  a  clear 
history  of  syphilis,  and  no  other  evidence  of  lupus. 

Treatment. — In  accordance  with  the  above  opinion,  iodide  of 
potassium  should  be  combined  with  iodide  of  iron.  Good  food, 
fresh  air,  and  phosphorized  cod-liver  oil  are  indicated.  Sea-air 
and  sea-bathing,  and  especially  the  bromo-iodine  water  of  Wood- 
hall  Spa,  Kreuznach  or  Challes,  both  internally,  locally,  and  in 
baths,  will  be  found  very  efficacious. 

The  galvano-cautery  is  particularly  valuable  in  destroying  this 
form  of  ulceration. 

TUBERCULAR  ULCERATION  OF  THE  MOUTH,  FAUCES,  AND 
PHARYNX  (Figs.  102  and  103,  Plate  XL). 

To  22  Isambert  and  Fraenkel,  above  all  others,  we  are  indebted 
for  accurate  description  of  this  unusual  affection,  and  for  insistance 
on  the  important  points  of  differential  diagnosis  necessary  for  its 
recognition. 


214 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Etiology  and  Pathology. — Specific  ulcerations  as  manifesta- 
tions of  tubercle  in  the  mouth,  fauces,  and  pharynx  are  much 
more  rarely  witnessed  than  in  the  larynx.  But  as  to  its  exact 
frequency  authors  vary  considerably.  According  to  ^^Heinze, 
tubercle  was  found  in  the  pharynx  14  times  in  1,226  cases  of 
pulmonary  tuberculosis.  This  estimate  approximately  agrees  with 
that  of  ^^Guttmann  and  Lublinski,  who  believe  that  only  i  per 
cent,  of  tuberculous  patients  are  affected  with  its  occurrence  in  the 
palate  and  pharynx.  On  the  other  hand,  Willigh  noted  only  one 
case  in  the  pharynx  out  of  1,317  collected  cases  of  general  tuber- 
culosis. Personally,  my  clinical  experience  inclines  me  to  agree 
with  the  estimate  of  Heinze  and  Guttmann.  Tuberculous  mani- 
festations of  the  larynx  occur  in  from  25  to  30  per  cent,  of  all 
cases;  and  the  number  of  such  cases  which  have  come  within 
my  scope  of  observation  since  my  attention  was  more  particularly 
drawn  to  the  subject,  ten  years  ago,  by  the  articles  of  Fraenkel 
and  Isambert,  may  at  a  low  estimation  be  placed  at  1,000.  I  have, 
however,  seen  but  ten  cases  with  pharyngeal,  buccal,  or  lingual 
manifestations ;  in  other  words,  in  about  '33  to  '25  per  cent,  of 
all  forms  of  tuberculosis,  and  about  i  per  cent,  of  those  exhibiting 
laryngeal  complications. 

Although  there  was  formerly  a  general  tendency — to  which 
individually  I  plead  guilty — to  view  all  ulcerations  in  this  region 
as  syphiHtic,  it  is  not  likely  that,  with  present  information,  this 
mistake  is  now  made  by  specialists ;  and  I  also  agree  with  Gutt- 
mann that  it  is  not  probable  that  these  cases  are  now  overlooked, 
for  the  twofold  reason  that  the  extreme  pain  experienced  by  the 
patient  at  once  enforces  our  attention  to  the  local  cause,  and 
because,  as  a  rule,  tubercular  ulceration  is  a  late  evidence  of  the 
general  disease.  As  to  this  last  fact,  however,  there  is  some 
difference  of  opinion.  I  have  reported,  in  conjunction  with 
^''Dundas  Grant,  two  cases  in  which  the  first  manifestation  in 
the  mouth  and  fauces  had  occurred  between  two  and  three  years 
previous  to  any  chest  attack,  or  even  the  suspicion  of  pulmonary 
disease.   To  these  the  following  is  of  sufficient  interest  to  be  noted : 

Matilda  H.,  aged  twenty,  married  at  sixteen,  is  the  mother  of  three  children,  of  whom 
the  youngest  is  fourteen  months  old,  and  is  *  just  being  weaned.'  She  herself  was  an  only 
child,  and  was  born  when  her  father,  who  is  still  living,  was  only  nineteen.  Her  mother  died 
before  she  could  remember.  The  patient  applied  at  the  Hospital  on  November  15,  1886,  cn 
account  of  pain  just  at  the  entrance  to  the  gullet.  No  pain  was  experienced  in  the  fauces, 
but  the  distress  was  so  extreme  lower  down  that  she  '  would  rather  not  swallow  so  as  to 
not  have  the  pain.'  There  was  slight  hacking  cough,  worse  at  night ;  and  but  little  altera- 
tion of  voice.  The  fauces  were  seen  to  be  of  characteristic  paleness,  and  on  the  left  tonsil, 
on  careful  inspection  and  with  bright  light,  there  was  discovered  slight  creeping  ulceration 
of  a  very  superficial  character,  and  with  but  scanty  secretion.    The  tonsils  were  not  in  the 


TUBERCULAR  ULCERATION  OF  THE  PHARYNX. 


2is 


least  enlarged,  nor  were  the  anterior  pillars  of  the  fauces  attacked  by  the  ulceration.  The 
back  of  the  mouth  was  full  of  frothy  saliva,  which  was  in  itself  a  source  of  distress,  as  the 
clearing  of  it  was  almost  as  painful  as  its  removal  by  swallowing.  The  larynx  was  healthy 
as  to  epiglottis  and  vocal  cords,  but  the  coverings  of  the  arytenoids  were  very  congested, 
and  there  was  slight  thickening  of  the  inter-arytenoid  fold.  The  posterior  wall  of  the 
pharynx  was  seen,  both  by  oral  and  laryngeal  examination,  to  be  ulcerated.  The 
appearance  of  the  ulceration  was  quite  distinctive  from  that  of  either  syphilis  or  cancer, 
and  was  characterized  by  the  presence  of  large  masses  of  weak  pale  granulations. 
There  was  no  enlargement  of  cervical  glands  in  any  direction,  and  no  part  pointing  to  any 
other  than  that  the  case  was  one  of  tuberculosis.  The  stethoscope  revealed  nothing  more 
than  slight  harshness  of  respiration,  and  somewhat  impaired  resonance  at  the  right  apex. 
There  had  been  no  distress  of  breathing,  and  neither  night  sweats  nor  diarrhoea.  She 
had  never  had  any  illness  affecting  her  chest  or  lungs.  Some  of  the  granulations  were 
scraped  away  and  submitted  to  microscopic  examination,  with  the  result  of  showing 
numerous  bacilli  of  tuberculosis. 

Isambert  has  given  one  case  of  a  child  aged  four  and  a  half 
years,  in  whom  there  were  typical  objective  signs  of  pharyn- 
geal tuberculosis,  without  any  pulmonary  symptoms  whatever. 
Fraenkel's  paper  also  contains  records  of  cases  which  are 
adduced  to  support  his  theory  that  miliary  tuberculosis  of  the 
pharynx  is  a  disease  which  may  attack  apparently  healthy  persons, 
though  it  can  hardly  be  admitted  that  his  cases  entirely  support 
his  thesis.  ^^Bosworth  is  inclined  to  the  same  opinion  as  Fraenkel, 
that  the  disease  is  frequently  primary  ;  but  in  the  only  case 
quoted  by  him, '  examination  of  the  lungs  showed  marked  dulness, 
with  broncho-vesicular  respiration  in  the  right  interscapular 
region,  eight  weeks  after  the  first  symptom  of  throat  trouble  was 
manifest,  and  four  weeks  after  the  graver  form  of  the  disease  of 
the  fauces  had  set  in.'  On  the  other  hand,  the  following  case  is  a 
striking  exemplification  of  the  more  general  view  that  pharyngeal 
ulceration  is  a  late  evidence  of  tuberculosis. 

J.  J.,  cet.  thirty-five,  was  admitted  into  the  Central  Throat  and  Ear  Hospital,  September 
9th,  1886,  on  the  recommendation  of  Mr.  Wade,  of  Southampton.  Although  he  had,  on 
a  previous  occasion,  eight  or  ten  years  ago,  lost  his  voice  for  a  time,  his  present  illness 
only  dated  from  September,  1885.  It  commenced  with  a  severe  cold  in  the  head,  followed 
by  hacking  cough  and  slight  expectoration  of  thick  phlegm,  which  was  only  freed  after 
attacks  of  cough  lasting  for  an  hour,  after  which  he  would  have  rest  for  two  or  three  hours. 
He  lost  his  voice  for  eight  or  ten  days,  but  almost  entirely  recovered  from  the  illness  in 
three  or  four  weeks.  All  the  symptoms  returned  at  Christmas,  1885,  and  have  not  since 
subsided.  From  this  date  he  has  lost  flesh.  Pain  and  difficulty  of  swallowing  were  first 
noticed  in  March,  1886  ;  about  this  time  he  gave  up  work,  and  though  he  has  done  a 
little  off  and  on  he  has  been  an  invalid  ever  since  that  time.  Diarrhoea  occurred  in 
August.  Has  never  spat  blood,  nor  had  night  sweats.  There  was  no  history  of  syphilis. 
He  had  been  married  nearly  four  years,  and  his  wife  had  given  birth  to  two  healthy 
children,  and  had  had  no  miscarriage. 

With  the  laryngoscope  there  was  seen  characteristic  thickening  of  the  arytenoid  cartilages 
and  vocal  cords,  but  there  was  no  ulceration  or  inflammation  of  the  fauces  or  soft  palate. 
Examination  of  the  chest  revealed  feeble  expansion,  increased  vocal  fremitus,  dulness, 
and  tubular  breathing  at  the  right  apex. 

The  patient  was  dh-ected  to  wear  an  oro-nasal  inhaler  with  the  inhalant  in  formula  ijj, 


2l6 


DISEASES  OF  THE  THROAT  AND  NOSE, 


and  to  take  hypophosphites  with  Fowler's  solution  ;  liquid  applications  or  insufflations  of 
chloride  of  zinc  and  morphia  (Form.  66  and  69)  were  employed  daily.  Under  this  treat- 
ment he  decidedly  improved,  but  on  October  5th  a  shallow  ulcer  was  observed  on  the  left 
tonsil  about  the  size  of  a  threepenny-piece,  which  was  judged  to  be  tuberculous,  though  it 
did  not  cause  pain,  that  symptom  being  manifested  only  at  the  orifice  of  the  oesophagus. 
The  ulcer  healed  after  one  application  of  the  galvano-cautery  on  October  7th  ;  cocaine 
having  been  previously  used  to  mitigate  the  pain  of  that  procedure. 

The  exact  etiology  of  this  form  of  the  disease  is  difficult  of 
determination,  but  there  is  the  invariable  element  of  a  low  state 
of  vitality,  with  a  resulting  feebleness  of  recuperative  power.  Its 
occurrence  as  a  primary  manifestation  of  the  tuberculous  diathesis 
is  at  least  as  doubtful,  but  still  as  possible,  as  is  that  of  a  primary 
tubercular  laryngitis.  All  arguments  to  this  effect  are  met  by  the 
fact  that  no  case  is  recorded  of  a  patient  dying  with  either  disease 
in  which  the  lungs  have  been  found  healthy  ;  and  in  this  connec- 
tion we  can  but  admit  that  the  ear  is  less  likely  than  the  eye  to 
detect  early  manifestations.  M}^  own  belief  is  in  accord  with 
that  of  Schech,  who  has  been  forced  to  the  conclusion  that  the 
pharynx  is  only  apparently  attacked  primarily  ;  in  other  words, 
that  prior  to  the  outbreak  of  pharyngeal  tuberculosis,  tubercular 
deposits  exist  in  other  organs,  although  the  fact  cannot  always  be 
demonstrated.  But  with  the  records  of  such  observers  as  have  been 
named,  and  in  recollection  of  our  own  cases,  it  would  be  rash  to 
assert  that  a  primary  tuberculous  ulceration  of  the  pharynx  is 
impossible.  Admitting  so  much,  many  local  causes  of  a  functional 
character  may  be  quoted  as  exciting  to  the  malady.  In  one  of 
our  cases,^^  the  local  irritation  of  diseased  teeth,  as  evinced  by 
the  improvement  following  their  extraction,  was  the  exciting 
cause  of  a  tuberculous  ulceration  of  the  gums  and  mouth,  which 
long  preceded  pulmonary  signs  ;  and  a  chronic  pharyngeal  catarrh 
may  be  as  much  a  factor  of  the  disease  in  this  region  as  is 
a  long-standing  and  neglected  laryngitis  of  laryngeal  phthisis. 
The  idea,  first  promulgated  by  very  eminent  pathologists,  that 
the  ulceration  could  arise  from  the  ir^-:tation  and  destructive 
action  of  pulmonary  sputa  is  less  capable  of  being  maintained  as  a 
cause  of  pharyngeal  tuberculosis  than  when  applied  to  the  same 
disease  in  the  larynx. 

I  have  quoted  the  fact  that  Isambert  has  seen  tuberculosis  of 
the  pharynx  in  a  young  child ;  and  a  few  other  similar  instances 
of  the  disease  in  the  young  have  been  recorded.  As  a  rule, 
however,  it  is  a  malady  of  adult  life.  The  division  of  tuberculous 
ulcerations  of  the  pharynx  and  fauces  into  acute  and  chronic  is 
fanciful  and  without  practical  utility. 

For  further  discussion  of  questions  of  causation  and  of  the 


TUBERCULAR  ULCERATION  OF  THE  PHARYNX.  2T7 


morbid  anatomy  of  tuberculosis  in  the  throat,  the  reader  is  referred 
to  the  chapter  on  *  Laryngeal  Phthisis.' 

Symptoms  :  Functional  or  Subjective. — The  voice  is  not, 
unless  there  be  concurrent  laryngeal  mischief,  affected  in  its  pho- 
netic character,  but  articulation  is  often  impaired,  and  frequently 
becomes  nasal.  Exercise  of  the  function  is  always  accompanied  by 
pain.  The  principal  symptom  is  the  extreme  agony  experienced 
in  deglutition,  whether  of  food  or  of  saliva.  The  pain  extends  to 
the  ear,  as  in  cancer,  by  transmission  through  Jacobson's  nerve, 
the  glosso-pharyngeal  and  the  auricular  branch  of  the  vagus. 
The  suffering  experienced  is  more  constant  and  probably  more 
acute  than  that  of  any  other  malady,  and,  as  Schech  states, 
patients  will  sometimes  rather  suffer  hunger  and  thirst  than 
endure  the  agony  of  deglutition.  The  senses  of  taste  and  of 
smell  may  be  affected.  The  odour  of  the  breath  is  very  charac- 
teristically offensive. 

Objective. — The  appearance  of  tuberculous  ulcers  in  the 
pharynx  or  on  the  tongue  is  very  characteristic  (Fig.  CX.). 


Fig.  ex.— Tuberculous  Ulceration       Fig.  CXI. — Larynx  of  the  same 
OF  THE  Velum  and  Fauces.  Patient  (j^"^  Chapter  on  Laryngeal 

Phthisis.) 

[The  subject  of  these  ilhistrations  was  a  male  patient,  aged  twenty-five,  who  had 
suffered  for  thirteen  weeks  from  dysphagia,  with  return  of  fluids  through  the  nostrils. 
His  chest  exhibited  symptoms  of  commencing  disease  at  the  right  apex.] 

They  are  irregularly  lenticular  in  shape,  with  ill-defined,  eaten  ou( 
and  slightly  raised  margins  of  a  pale  yellow  colour,  and  with  but 
faintly  hyperaemic  areola.  On  their  floor,  which  is  shallow,  ma}^  be 
observed  several  grain-like  granulations  or  warty  excrescences  of 
pale  pink  colour,  covered  with  thin  unhealthy  pus.  The  soft  palate 
may  be  thickened,  and  the  uvula  enlarged  vv^ith  the  semi-solid 
effusion  pecuhar  to  tuberculosis,  submucous  infiltration ;  but 
more  frequently  there  is  thinning  and  atrophy  of  these  tissues. 
The  mucous  membrane  generally  of  the  buccal  cavity  and  palate 
is  of  the  characteristic  pale-greyish  colour  to  be  later  insisted  on 
as  pathognomonic  of  laryngeal  phthisis  ;  and  studded  about. 


-218  DISEASES  OF  JHE  THROAT  AND  NOSE, 

especially  in  the  neighbourhood  of  the  ulcers,  may  sometimes  be 
seen  small  greyish  nodules,  to  the  caseous  degeneration  of  which 
the  ulcer  probably  owes  its  origin.  Indeed,  Schnitzler  has  pub- 
lished a  case  in  which  he  diagnosed  tuberculosis  merely  from  the 
presence  of  such  tiny  greyish  tumours  upon  the  uvula  and  arch 
of  the  palate,  when  no  point  of  ulceration  appeared  either  in  the 
pharynx  or  larynx,  and  when  no  disease  of  the  lungs  could  be 
determined  by  physical  examination.  He  excised  some  of  the 
tumours  which,  examined  by  the  microscope,  proved  to  be  true 
miliary  tubercles.  Later,  typical  tuberculous  ulcerations  made 
their  appearance  on  the  site  of  the  patches  in  the  pharynx, 
and  the  usual  signs  of  pulmonary  phthisis  developed  themselves. 
In  one  of  my  cases,  ulceration  of  the  tongue,  and  in  another  of 
the  pharynx,  existed  two  years  and  a  half  and  three  years  respec- 
tively before  any  manifestation  of  pulmonary  trouble  could  be 
recognised,  though  the  ulceration  was  diagnosed  and  treated  as 
tuberculous  so  soon  as  seen  by  Dr.  Dundas  Grant  and  myself. 
The  later  development  of  pneumonic  symptoms  testified  to  the 
correctness  of  our  opinion.  Cases  have  been  reported  of  tuber- 
culosis of  the  pharyngeal  tonsil,  and  other  portions  of  the  naso- 
pharynx. I  have  not  myself  seen  any  manifestation  in  that 
region,  but  I  have  more  than  once  had  experience  during  the 
course  of  a  pharyngo-laryngeal  tuberculosis  of  a  suppurative 
inflammation  of  the  middle  ear,  which  probably  originated  by 
extension  of  the  disease  along  the  Eustachian  tube.  The  intense 
pain  felt  in  the  ear,  as  an  almost  constant  sign  of  pharyngeal 
tuberculosis,  but  not  specially  characteristic  of  this  form  of  inflam- 
mation, might  well  account  for  a  non-recognition  of  such  a 
condition  prior  to  the  occurrence  of  purulent  discharge.  It  is 
highly  probable  that  tuberculosis  of  the  faucial  tonsils  is,  as 
Strassmann  (quoted  by  Schech)  has  observed,  a  common  but 
unrecognised  accompaniment  of  pulmonary  tuberculosis.  He 
believes  that  in  such  circumstances  the  symptoms  are  negative. 
The  cases  of  M.  H.  and  of  J.  J.,  which  I  have  quoted,  would  support 
this  view ;  but  it  is  important  to  note  that  in  neither  of  them  was 
there  any  ulceration  of  the  pillars  of  the  fauces. 

The  DIAGNOSIS  need  never  be  doubtful  if  the  practitioner  is  only 
alive  to  the  possibility  of  its  existence,  as  the  only  disease  for 
which  pharyngeal  tuberculosis  can  be  mistaken  is  syphilis  in  its 
tertiary  form.  ^sgQs-y^Qj-^]^  j^a^s  so  well  classified  the  distinctions 
between  these  two  diseases  that  I  adopt  his  grouping  with  only 
slight  modifications  and  additions.  He  has  added  a  third  column 
of  the  differential  signs  of  scrofulous  ulcers,  but  since  I  do  not 
recognise  that  disease  I  have  omitted  it : 


TUBERCULAR  ULCERATION  OF  THE  PHARYNX.  219 


Tuberculous  Ulcers. 

No  apparent  excavation. 
Much  indolent  granulation. 


Syphilitic  Ulcers. 
Deeply  excavated. 

Few  granulations,  and  those  highly 

inflammatory. 
Deep  red  areola. 
Sharply-cut  edges. 
Distinct  demarcation. 
Yellow  purulent  secretion. 
Discharge  profuse. 
Penetrating  to  deeper  tissues. 

No  fever. 


Faint  areola. 

Irregular  and  ill-defined  edges. 
Demarcation  indistinct. 
Greyish,  ropy  mucous  secretion. 
Discharge  scanty. 

Superficial,  with  lateral  in  place  of  deep 

extension. 
High  fever. 


To  the  consideration  of  these  local  differences  are  to  be  added 
those  of  the  general  history  and  emaciation,  and  of  (possibly) 
concurrent  evidences  in  the  individual  and  family  history. 

With  regard  to  external  signs,  the  submaxillar}^,  parotid,  and 
lateral  cervical  glands,  both  deep  and  superficial,  are  often 
swollen  and  painful  in  tuberculosis,  but  are  unaffected  in  syphilis. 
In  the  earlier  stages  of  this  last  complaint  there  of  course  exists 
the  well-known  post-cervical  glandular  enlargement  to  be  felt  in 
the  nape  of  the  neck,  but  this  condition  is  by  no  means  so 
common  in  the  later  secondary  or  tertiary  manifestations — those 
likely  to  be  mistaken  for  tuberculosis.  As  far  as  the  glandular 
evidences  are  concerned  the  disease  might  be  more  excusably 
mistaken  for  cancer ;  but  examination  of  the  ulceration  itself,  as 
well  as  numerous  other  symptoms,  at  once  differentiates  it.  Nor 
is  there  the  shghtest  justification  for  the  suggestion  that  tubercu- 
lous ulceration  of  the  fauces  or  pharynx  has  any  objective 
symptoms  likely  to  lead  to  its  being  diagnosed  as  diphtheria. 

Temperature  as  a  diagnostic  point  is  of  by  no  means  the  value 
that  might  generally  be  supposed ;  and  I  have  not  found  the 
variations  of  such  extent  as  is  usual  in  ordinary  cases  of  pul- 
monary phthisis.  This  is  due,  no  doubt,  to  the  inanition  caused 
by  the  odynphagia,  which,  in  its  turn,  contributes  so  much  to 
the  more  rapidly  fatal  termination  of  the  disease. 

Lastly,  diagnosis  may  be  completed  by  examination  for  the 
tubercle  bacillus,  which  can  usually  be  obtained  without  difiiculty 
from  this  region. 

Prognosis  is  seldom  doubtful.  Whether  such  a  disease 
as  primary  tuberculosis  of  the  pharynx  is  or  is  not  possible, 
it  is  beyond  question  that  up  to  now  no  case  has  been 
reported  of  a  cure.  In  this  respect  the  pharyngeal  disease  offers 
us  less  hope  than  is  beginning  to  obtain  regarding  pulmonary  and 
laryngeal  manifestations  of  the  tuberculous  dyscrasia,  and  par- 
takes of  the  obstinate  progress  to  a  fatal  termination  of  the  same 


220 


DISEASES  OF  THE  THROAT  AND  NOSE, 


disease  in  any  part  of  the  alimentary  tract.  The  issue,  in  the 
light  of  an  accurate  diagnosis,  may  be  surely  foretold  long  before 
pulmonary  and  other  more  commonly  recognised  symptoms  are 
far  advanced ;  but  it  may  be  long  delayed.  For  general  guidance 
it  may  be  stated  that  the  prognosis  is  unfavourable  as  to  duration 
of  life,  in  proportion  to  the  increase  of  the  dysphagia,  and  the 
consequently  diminished  powder  of  taking  nutriment. 

Treatment  can,  at  the  best,  be  but  palliative.  The  indications 
are  : 

1.  To  counteract  the  general  phthisical  processes. 

2.  To  give  as  much  as  possible  functional  rest. 

3.  To  relieve  the  pain  in  swallowing. 

4.  To  administer  suitable  nourishment. 

5.  To  heal  the  ulceration. 

Going  briefly  through  all  these  points  separately,  it  may  be 
said  that — (i)  The  hypophosphites  and  malt  extracts,  from  their 
respectively  special  properties  in  aiding  assimilation  of  meat  and 
starch  foods,  are  probably  of  greater  service  in  pharyngeal  than  in 
most  forms  of  laryngeal  tuberculosis.  Cod-liver  oil,  taken  in  com- 
bination with  the  two  foregoing  remedies,  is  generally  of  good 
effect,  but  is  not  always  well  borne.    (2)  Functional  rest  by  disuse 
of  the  voice  is  equally  important  in  palatal  and  lingual,  as  in 
laryngeal  cases.    Where  dysphagia  is  extreme,  administration  of 
food  by  the  oesophageal  tube  or  per  rectum  is  often  called  for,  and 
if  maintained  for  a  few  days  will  sometimes  be  attended  by  such 
improvement  in  deglutition  that  oral  alimentation,  tlius  rested, 
can  be  resumed.    For  this  purpose  of  giving  rest,  in  cases  of 
dysphagia  due  to  ulceration,  it  was  first  advocated  by  Bryson 
Delavan.     It  must  be  remembered  that  the  passage  of  the 
oesophageal  tube  is  in  itself  painful,  and  the  pre-application  of  a 
4  or  5  per  cent,  solution  of  cocaine  is  advisable.     '^^  Beverley 
Robinson  lays  stress  on  the  advisability  of  rinsing  the  stomach 
with  an  alkaline  tepid  solution  in  those  cases  in  which  long 
restraint  from  food  has  led  to  distaste  or  disgust  for  nutriment. 
He  also  thinks  it  is  often  unnecessary  to  pass  the  tube  far  beyond 
the  commencement  of  the  oesophagus  proper.    The  tubes  should 
be  of  small  calibre.    (3)  Relief  of  the  pain  in  swallowing  is  to  a 
large  extent  involved  in  (4)  The  form  of  nutriment  to  be  prescribed. 
The  food  should  be  soft  and  thickened,  and,  as  a  type,  I  may 
allude  to  the  raw  egg,  either  beaten  up  with  milk  or  wine,  or 
preferably  simply  thrown  whole  out  of  the  shell  into  a  glass.  This, 
flavoured  with  a  few  drops  of  vinegar,  should  be  swallowed  at  a 
^ulp,  and  so  taken  it  acts  both  as  nutriment  and  as  a  soothing 
and  protective  application.    Oysters,  thickened  soups,  cream, 
milk,  etc.,  will  all  suggest  themselves  as  suitable  in  less  extreme 


TUBERCULAR  ULCERATION  OF  THE  PHARYNX.  221 


cases.  As  to  the  temperature  of  the  food,  cold  fluids  are  better 
borne  than  hot,  which  always  increase  the  pain.  Sometimes  ice 
is  distinctly  grateful  and  ease-giving.  But  probably  tepid  food 
will  be  most  generally  acceptable  and  less  likely  to  either  irritate 
the  ulceration  or  to  cause  muscular  cramp. 

Of  more  purely  medical  modes  of  relief  the  application  of  a  five 
or  ten  per  cent,  solution  of  cocaine  shortly  before  food-taking  has 
superseded  all  previous  anodyne  applications,  such,  for  instance, 
as  the  morphiated  glycerine  of  Isambert,  which  indeed,  undiluted 
with  water,  I  have  found  irritating  rather  than  sedative.  Nor 
have  I  found  insufflation  of  either  morphia  or  iodoform  of  service 
in  pharyngeal  ulceration.  Prior  to  introduction  of  cocaine,  I 
employed  a  solution  of  chloride  of  zinc  and  morphia  (Form.  66). 
A  preparation  of  benzoin,  opium,  and  belladonna,  mixed  with  yolk 
of  egg  (Form.  67),  was  of  noted  service  in  one  case  for  which  it  was 
specially  prescribed.  I  would  still  suggest  these  applications  as 
alternatives  of  cocaine,  when,  as  is  not  unfrequently  the  case  after 
long-continued  use,  that  drug  has  lost  its  effect,  and  the  variation  of 
the  other  mineral  astringent  solutions  which  are  likewise  men- 
tioned in  the  list  of  Formulae  with  addition  of  cocaine  or  morphia. 
Externally,  hot  or  cold  applications  by  means  of  Leiter's  coil  are 
one  or  other  agreeable,  according  to  individual  proclivities.  Bella- 
donna and  chloroform,  and  the  application  of  chloral  and  camphor 
(Form.  57),  are  also  amongst  the  external  remedies  worthy  of 
trial.  The  sipping  of  barley-water  or  milk  and  water  containing 
solution  of  morphia  in  very  diluted  proportions  (not  more  than  i 
per  cent.)  is  of  advantage  in  giving  ease  to  both  local  pain  and  to 
distress  of  cough. 

Lastly,  is  there  any  way  or  hope  of  healing  the  ulcerations  ? 
Applications  of  the  zinc  and  copper  solutions,  combined  with 
anodynes,  have  not  been  followed  by  any  favourable  results. 
Free  application,  with  friction,  of  lactic  acid,  the  granulations 
having  been  previously  scraped  by  a  curette,  has  been  extolled  by 
many,  especially  by  Krause  of  Berlin  ;  and  my  experience,  which 
was  but  limited  when  I  wrote  my  last  edition,  has  confirmed  me  in 
the  highest  opinion  of  its  value  ;  the  same  may  be  said  of  menthol, 
as  recommended  by  Rosenberg  of  the  same  city.  In  one  case  of 
lingual  tuberculosis,  and  in  one  of  tonsillar  ulceration,  the 
galvano-cautery  rendered  such  good  service  that  a  trial  of  it 
can  with  confidence  be  recommended ;  and  the  more  so,  since 
with  the  introduction  of  cocaine  the  proceeding  is  not  attended 
by  such  acute  pain  as  formerly.  After-pain  there  is  little,  for,  as 
I  have  often  pointed  out,  galvanic  has  antiseptic  and  healing 
properties  unpossessed  by  any  other  form  of  actual  cautery. 

Employment  of  an  oro-nasal  inhaler,  with  some  such  antiseptic 


222 


DISEASES  OF  THE  THROAT  AND  NOSE. 


and  anodyne  mixture  as  that  mentioned  in  Form.  52  and  53,  is 
of  utility  in  relieving  the  disagreeable  taste  and  odour  of  the 
breath,  and  when  the  disease  has  extended  to  the  larynx  or  lungs, 
in  checking  cough  and  expectoration. 

LUPUS  AND  LEPRA  OF  THE  PHARYNX  AND  FAUCES. 

The  first  of  these  diseases,  when  manifested  in  the  throat,  is 
so  generally  associated  with  extension  to  the  larynx,  that  it  will 
be  described  amongst  the  diseases  of  that  region. 

Lepra  of  the  pharynx  is  of  great  rarity  in  this  country,  but  by 
the  courtesy  of  Dr.  Dickson,  I  recently  had  an  opportunity  of  see- 
ing a  few  cases  at  the  Leper  Establishment,  Robben  Island, 
Cape  Town.  Its  general  history  is  similar  to  that  of  lupus,  pos- 
sessing, as  it  does,  the  two  prominent  characteristics  of  that 
disease,  viz.,  that  it  is  secondary  to  cutaneous  manifestations, 
and  that  when  it  heals  it  leaves  behind  an  indelible  scar.  The 
prognosis  as  to  cure  is  in  the  last  degree  unfavourable. 

NEUROSES  OF  THE  PHARYNX  AND  FAUCES. 

Nervous  affections  of  the  palate  and  pharynx  are  by  no  means 
rare,  and  occur  as  symptoms  or  as  complications  of  a  great  variety 
of  pharyngeal  diseases.  As  in  other  regions,  pharyngeal  neuroses 
may  be  conveniently  divided  into  impairment  of  the  sensory  and 
of  the  motor  functions. 

Motor. — Anaesthesia  of  the  pharyngeal  mucous  membrane  is 
said  to  occur  in  typhus  and  cholera,  and  is  also  common  in 
general  paralysis  of  the  insane.  From  an  investigation  into  the 
condition  of  the  throat  in  fifty  patients  suffering  from  the  last- 
named  disease,  made  by  ^ime  in  1875,  at  the  invitation  of  Sir 
Crichton  Browne,  it  appears  that  the  reflex  excitability  of  the 
pharynx  is  markedly  diminished  from  the  beginning  of  the  disease, 
and  prior  to  development  of  motor  symptoms.  Anaesthesia  of 
the  pharynx  may  also  be  present  in  connection  with  epilepsy  and 
as  the  result  of  paralysis  of  the  glosso-pharyngeal  or  pneumogastric 
nerves.  In  all  these  cases  the  origin  of  the  neuroses  is  central. 
Of  peripheral  origin,  the  chief  is  the  insensibility  accompanying 
post- diphtheritic  paralysis,  and,  on  cicatrization  of  syphilitic  and 
other  ulcerations.  Lupoid  and  leprous  cicatrices  are  said  to  retain 
their  sensibility.  Hysteria  is  another  cause  of  pharyngeal  anaes- 
thesia. Finally,  it  can  be  induced  by  the  action  of  ice,  or  of 
extreme  cold  otherwise  applied,  and  of  certain  drugs,  as  chloro- 
form, bromides  of  potassium,  sodium,  or  ammonium,  morphia, 
and  especially  of  cocaine. 

Hyperaesthesia  can  hardly  be  said  to  exist  as  a  disease,  but 


NEUROSES  OF  THE  PHARYNX  AND  FAUCES.  223 

the  presence  of  an  elongated  uvula,  or  other  stimulus  of  irritation, 
may  produce  excessive  sensitiveness  of  the  part.  In  chronic 
pharyngitis  there  is,  so  long  as  congestion  remains,  a  decided 
increase  of  sensitiveness,  due  to  reflex  irritation,  and  it  is  a 
common  impediment  to  laryngoscopic  examinations  and  intra- 
laryngeal  operations. 

Paraesthesia,  or  abnormal  sensations  in  the  pharynx  and,  it 
may  be  added,  in  the  mouth,  are  very  common.  Disagreeing 
with  some  other  writers,  they  are  always,  in  my  opinion,  sympto- 
matic of  some  objective,  but  not  always  discovered,  cause.  The 
chief  of  such  feelings  are  those  of  a  heat,  a  pricking,  a  swelling,  a 
weight,  a  straw,  a  hair,  or  other  foreign  body,  and  the  rising  of  a 
lump  in  the  throat  {globus  hystericus).  One  patient,  an  otherwise 
strong,  hale  farmer,  complained  of  a  feeling  of  intense  cold  with 
exacerbation  on  swallowing  and  after  food-taking.  The  character- 
istic cramp-like  contractions,  and  attempts  at  swallowing  even 
when  not  eating,  constitute  a  veritable  faucial  and  pharyngeal 
tenesmus^  a  term  quite  appropriate  to  the  symptoms  now  under 
consideration,  since,  as  will  presently  be  shown,  the  sensations 
depend  on  almost  exactly  similar  constitutional  and  local  causes 
as  those  leading  to  rectal  or  vesical  spasm  and  tenesmus. 

As  the  result  of  examination  of  a  large  number  of  cases,  made 
in  1878  in  conjunction  with  my  colleague.  Dr.  Dundas  Grant, 
when  he  was  Registrar  of  the  Central  Throat  and  Ear  Hospital, 
I  arrived  at  the  conclusion  that  there  are  but  very  few  cases  of  a 
purely  hysterical  character ;  and  I  read  a  paper  on  the  subject 
at  the  International  Laryngological  Congress  in  Milan  in  1880, 
and  again  before  the  Philadelphia  Medical  Society  in  1887.  The 
correctness  of  my  views  has  since  been  confirmed  by  several  in- 
dependent and  quasi-original  communications. 

Fig.  CXII.  represents  a  typical  portrait  of 
lingual  varix,  which  was  taken  from  a  maiden 
lady,  aged  fifty-two,  sent  to  me  by  Mr. 
Hemming,  of  Notting  Hill.  She  complained 
of  pain  in  her  tongue  and  back  of  the  throat, 
with  sensation  of  an  obstruction,  and  cramps, 
which  she  believed  to  be  rheumatic.  She  had 
become  thinner,  and  dreaded  malignant  disease. 
She  suffered  from  habitual  constipation  and 
rectal  haemorrhoids.  Her  throat-suffering  dated 
from  the  menopause,  which  had  occurred  rather 
more  than  a  year  previously. 

The  following,  in  order  of  fre- 
quency, are  the  principal  objective 
conditions  to  be  found  : 
(i)  Varicose  veins  at  the  base  of  the  tongue,  dependent  (a)  on 


224 


DISEASES  OF  THE  THROAT  AND  NOSE, 


a  general  or  local  vaso-motor  neurosis,  and  associated  in  females 
with  menorrhagia  or  amenorrhoea.  In  several  cases,  as,  for 
instance,  in  that  quoted  above,  the  trouble  dates  from  the  meno- 
pause ;  and  in  one  male  case  recently  under  my  care,  a  gentleman 
aged  50,  his  v^ife  remarked  that  there  is  a  slight  accumulation  of 
blood  found  in  the  mouth  for  from  three  to  five  successive 
mornings,  the  throat  attacks  occurring  with  remarkable  monthly 
regularity.  And  {h)  on  a  similar  condition  as  a  result  of  alcoholism. 
Haemorrhoids,  varicocele  and  varix  of  the  lower  limbs  are  frequent 
concurrent  evidences  of  the  dyscrasia.  To  see  this  condition  it  is 
necessary  to  place  the  mirror  high  up  in  the  throat.  ^'^Dickson 
considers  varicosity  of  the  ranine  and  lingual  veins  on  the  anterior 
under  aspect,  and  at  the  side  of  the  tongue,  a  diagnostic  sign  of 
value  in  relation  to  thrombotic  and  haemorrhagic  lesions  of  the 
brain,  and  also  to  cardiac  weakness.  I  have  seen  two  cases 
associated  with  diabetes,  a  circumstance  to  be  calculated  with 
when  forming  a  prognosis.  Dr.  Pavy,  to  whom  I  sent  one  of 
these  patients,  wrote  :  '  /  also  am  often  led  to  suspect  sugar  in 
the  urine,  from  an  injected  appearance  of  the  mouth  and  fauces. 
Assuming  the  existence  of  a  vaso-motor  paralysis  here,  the 
condition  may  be  more  extensive,  and  involve  also  the  vessels  of 
the  chylo-poietic  viscera,  and  thus  lead  to  sugar  in  the  urine.' 

(2)  Hypertrophy  of  the  lingual  tonsil,  a  condition  often 
associated  with  dyspepsia.  Sometimes  in  this  variety  the  epi- 
glottis will  become  *  imprisoned,'  as  Cohen  has  termed  it. 

(3)  Slight  enlargement,  or  at  least  congestion  and  sensitiveness 
on  touch,  of  the  thyroid  gland.  In  many  instances  in  which 
there  is  but  slight  enlargement  of  the  gland,  the  pecuHar  thrill  of 
venous  congestion  will  be  felt  on  palpation  of  the  thyroid  region. 

The  etiological  factors  in  the  production  of  this  overgrowth  of 
the  lymphoid  tissues  at  the  base  of  the  tongue  are  apparently 
identical  with  those  leading  to  enlargement  of  the  other  faucial 
and  pharyngeal  lymphoid  glandular  masses,  namely,  the  contam- 
ination of  the  buccal  fluids  by  micro-organisms  and  their  irritating 
chemical  products — the  result  of  their  life  processes — in  associa- 
tion with  rheumatic  and  other  diatheses.  In  corroboration  of 
this  statement,  I  may  mention  that  I  have  often  seen  in  septic  and 
rheumatic  anginse,  a  complete  blocking  of  the  lacunae  at  the  base 
of  the  tongue,  a  precisely  similar  condition  to  that  which  in  the 
faucial  tonsils  is  erroneously  described  in  even  modern  text-books 
as  'follicular  inflammation,'  and  still  more  ignorantly  as  'ulcerated 
sore  throat.' 

Undoubtedly  these  abnormal  feelings  are  more  common  amongst 


NEUROSES  GF  THE  PHARYNX  AND  FAUCES 


225 


females  than  males,  but  enough  has  been  said  to  show  that  they 
must  not  on  that  account  be  dismissed  as  groundless  fears  of  an 
imaginative  or  hysterical  hypochondriac.  Since  I  began  to  search 
for  a  cause  I  have  found  these  cases  yield  to  remedies  appropriate 
to  the  circumstance,  and  my  colleagues  agree  with  me  in  finding 
them  perfectly  amenable  to  treatment.  Although  hardly  to  be 
considered  as  an  abnormal  sensation,  mention  may  here  be  made 
of  the  taste  of  blood  in  the  throat  on  waking  from  sleep.  I  have 
repeatedly  assured  myself  that  such  an  experience  is  always  the 
result  of  an  actual  venous  leakage,  and  a  common  symptom  of  varix. 

Treatment  consists  in  rectifying  the  irritant  character  of  the 
oral  secretions,  and  in  removing  redundant  tissue  by  either  the 
galvano-cautery — preferably  the  porcelain  point — or  with  the 
galvano-caustic  snare.  Lunar  caustic  is  an  inefficient,  and 
chromic  acid  a  dangerous  application  in  this  situation.  ^^Walter 
Fowler  and  others  have  reported  cases  in  which  this  last  remedy, 
so  employed,  passed  into  the  stomach  and  caused  collapse  and 
other  toxsemic  effects. 

That  very  evident  diminution  of  swelling  of  the  thyroid  gland 
frequently  results  from  this  treatment  as  well  as  after  removal  of 
hypertrophied  faucial  and  pharyngeal  tonsils,  is  a  fact  none  the 
less  remarkable  than  the  subsidence  of  enlarged  glands  in  the 
neck  after  rectifying  morbid  conditions  of  the  mouth  and  throat. 

Spasm  of  the  Pharynx  may  to  some  extent  be  considered  as  a 
motor  neurosis,  but  is  often  a  subjective  symptom.  It  is  met  with, 
independently  of  paraesthesia,  in  an  extreme  degree  in  oedematous 
and  acute  inflammations,  and  in  hydrophobia.  In  its  milder  forms 
it  may  be  due  to  incomplete  mastication,  arising  from  absence  of 
teeth,  or  the  imperfect  *  bite '  of  an  artificial  set.  It  is  to  be  dis- 
tinguished from  organic  disease  by  the  fact  that  the  patient  has 
difficulty,  never  actually  amounting  to  inability,  of  deglutition, 
quite  irrespective  of  the  consistence  or  temperature  of  the  food. 
An  important  diagnostic  sign  of  this  form  of  dysphagia,  and  not, 
I  believe,  previously  noted,  is  the  condition  of  the  muscles  of 
mastication.  If  the  surgeon  places  his  fingers  over  the  masseter 
and  temporal  regions  he  will  find  that,  on  the  patient  making 
movements  of  mastication,  those  muscles  are  more  or  less 
atrophied,  the  result  of  disease.  Not  so  in  organic  cases,  where 
the  teeth  are  perfect  and  mastication  has  been  exercised  even 
to  excess.  The  oesophageal  bougie  or  digital  examination  will 
complete  the  diagnosis.  Spasm  is  also  a  symptom  of  chronic 
pharyngitis  ;  and  lastly,  and  above  all,  it  occurs  in  the  trouble 
known  as  globus  hysterictiSy  to  which  allusion  has  just  been  made. 

15 


226 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Neuralgia,  due  to  the  same  causes  as  those  which  produce  similar 
disorders  in  other  regions,  may  occur  in  the  throat,  and  must  be 
treated  on  general  rather  than  on  purely  local  indications.  It  is 
decidedly  rare,  but  I  have  seen  some  cases  of  extreme  and  re- 
mittent pain  analogous  to  neuralgia  of  the  fifth  or  of  the  sciatic 
nerve,  but  without  any  local  sign  of  surface  inflammation,  which  by 
exclusion  could  be  considered  only  as  neuralgic,  and  which  have 
yielded  to  remedies  appropriate  to  that  diagnosis.  I  cannot  agree 
with  ^^Schech  as  to  the  uniformity  or  even  common  association  of 
such  symptoms  with  hysteria.    (See  '  Neuralgia  of  the  Larynx.') 

Female  patients  are  much  more  hable  than  males  to  these 
nervous  affections,  and  will  in  such  case  generally  be  found  to 
suffer  either  from  menorrhagia  or  amenorrhoea. 

Treatment  of  all  neuroses  of  the  pharynx  must  be  directed 
especially  to  the  removal  of  the  cause.  In  pharyngeal  anaesthesia 
of  extreme  character  artificial  feeding  must  be  pursued,  so  long 
as  there  is  fear  of  food  entering  the  air-passages  ;  faradization 
and  subcutaneous  injection  of  strychnia,  with  tonics  of  iron, 
quinine,  and  strychnia,  are  the  principal  therapeutic  agents. 
Friction  and  possibly  modified  massage  might  be  of  value. 

In  hyperaesthesia,  when  it  interferes  with  laryngeal  examina- 
tions, removal  of  the  cause,  as  in  the  case  of  a  relaxed  uvula,  and 
modulation  of  the  sensibiHty  in  those  of  pharyngitis,  tuberculosis, 
etc.,  by  anodyne  applications,  the  chief  of  which  is  cocaine,  are 
naturally  at  once  suggested.  Although  trenching  on  the  laryn- 
geal portion  of  this  treatise,  it  may  here  be  conveniently  remarked 
that  the  constant  touching  of  the  intra-laryngeal  parts  with  the 
probe,  as  recommended  by  many  authorities,  for  the  purpose  of 
rendering  them  accustomed  to  instruments  preliminary  to  opera- 
tions— as  for  removal  of  growths — is  a  procedure  neither 
practised  nor  advocated  by  us. 

The  treatment  of  paraesthesia,  as  has  already  been  suggested, 
depends  essentially  on  a  proper  diagnosis  and  therapeutic  action 
thereon.  With  regard  to  spasm,  the  same  may  be  said.  In  the 
case  of  varix  the  enlarged  vessels  are  to  be  destroyed  by  the 
galvano-cautery,  cocaine  being  first  employed.  Where  a  battery 
is  not  available  the  acid  nitrate  of  mercury  is  the  most  efficient 
caustic.  It  was  held  in  great  esteem  by  my  friend  Llewelyn  Thomas. 

When  the  teeth  are  at  fault,  it  is  most  important  to  call  in  the 
aid  of  the  dentist,  not  only  for  immediate  and  permanent  relief, 
but  because  without  doubt  many  cases  of  malignant  ulceration 
commence  with  symptoms  ascribed  to  purely  functional  causes. 
Faradization,  by  means  of  the  oesophageal  electrode  (simply  an 


DEFORMITIES  AND  MORBID  GROWTHS  OF  THE  PHARYNX.  227 


elongation  of  the  laryngeal  instrument),  is  of  possible  service  in 
restoring  healthy  muscular  action.  In  one  case  that  came  under 
my  care  on  the  recommendation  of  Mr.  Poyntz  Wright,  of  Old- 
ham, this  treatment  had  been  of  no  avail,  and  the  patient 
recovered  under  the  subcutaneous  injection  of  TT|_ij.  to  T(\jv,  of  the 
B.  P.  solution  of  strychnia. 

Motor  paralysis  of  the  pharynx  is  usually  of  central  origin, 
and  may  be  due  to  injury  or  disease  of  the  brain  and  pneumo- 
gastric,  or  in  its  peripheral  form  as  a  sequel  of  many  wasting 
diseases,  and  especially  of  diphtheria.  Paresis  and  paralysis  of 
the  velum  is  commonly  associated  with  a  chronic  relaxation  of 
the  uvula,  as  well  as  of  acute  catarrhal  inflammation  of  the  fauces. 

Treatment  in  the  peripheral  class  of  cases  must  consist  in  the 
exhibition  of  general  tonic  remedies,  the  application  of  local 
faradization,  hypodermic  injections  of  strychnia,  and  the  adminis- 
tration of  thoroughly  soft,  and,  if  necessary,  artificially  masti- 
cated food.  The  prognosis  is  favourable,  except  where  +.he 
symptoms  are  due  to  centric  causes,  when  the  outlook  is,  of 
course,  quite  the  reverse.  Such  cases  are,  however,  con^^idered 
in  systematic  works  on  medicine,  and  do  not  here  require  further 
elaboration. 

MALFORMATIONS,  DEFORMITIES,  AND  MORBID  GROWTHS 
OF  THE  PHARYNX. 

Malformations  of  the  pharynx  consist  principally  of  Stenoses, 
which  may  be  primary,  and  due  to  a  congenitally  imperforate  state 
of  the  tube,  of  which  there  are  several  examples  in  the  museum 
of  the  College  of  Surgeons  ;  and  secondary,  which  are  mainly  those 
arising  from  some  inflammatory  process,  constitutional  or  trau- 
matic, to  be  further  subdivided  into  intrinsic  and  extrinsic. 

The  passage  may  be  more  or  less  constricted  as  the  result  of 
syphiHtic  cicatrization,  and  the  canal  may  also  be  narrowed 
temporarily  by  an  abscess.  Both  these  two  last-named  con- 
ditions have  been  already  considered. 

Dilatation  of  the  pharynx — Pharyngocele — leading  to  the  for- 
mation of  a  pouch,  in  which  the  food  is  apt  to  lodge,  is  occasionally 
witnessed  as  the  result  of  enfeeblement  of  the  constrictors,  and  is 
also,  though  rarely,  congenital.  The  condition  gives  rise  to 
symptoms  of  discomfort  rather  than  danger.  The  chief  is  that 
due  to  the  lodgment  of  food  in  the  pouch.  The  only  danger  is 
the  possible  passage  of  food  into  the  larynx.  But  little  is  to  be 
done  in  the  way  of  treatment.  After  a  time  the  patient  often 
learns  by  peculiar  movements  of  the  throat,  or  by  external  pressure, 


228  DISEASES  OF  THE  THROAT  AND  NOSE. 


to  empty  the  sac  ;  otherwise  this  is  done  by  Nature  herself  when- 
ever the  receptacle  becomes  overloaded.  Surgical  treatment 
cannot  be  recommended. 

^^Cohen  has  noted  a  peculiarity,  to  which  my  colleague, 
Dundas  Grant,  has  twice  drawn  my  attention,  namely,  a  separate 
mucous  investment  of  the  palato-glossus  muscle  in  the  anterior 
fold  of  the  palate,  leaving  sometimes  on  one  side,  sometimes  on 
both,  an  opening  between  the  anterior  and  posterior  pillars,  which 
might  easily  be  mistaken  for  ulcerative  destruction  of  tissue.  I 
cannot  agree  with  a  ^^recent  writer  that  they  are  really  of  patho- 
logical origin,  such  as  scarlatina  or  quinsy. 

I  have  found  but  very  scant  mention  of  another  cause  leading  to 
narrowing  of  the  lower  pharynx,  namely,  angular  curvature  of  the 
cervical  portion  of  the  spinal  column.  Such  a  case  occurred  in 
my  practice,  and,  as  it  offers  many  points  of  diagnostic  interest, 
may  be  briefly  related. 

The  patient,  a  gentleman,  aged  fifty,  came  under  observation  October  23rd,  1877.  He 
complained  of  continual  snuffling  and  accumulation  of  phlegm,  of  foetid  taste  and  odour, 
dropping  into  the  throat  from  the  post -nasal  passages.  Deglutition  was  difficult,  except 
with  soft  food  and  fluids.  Respiration  was  very  short ;  the  voice  had  become  feeble,  and 
was  occasionally  lost  *  as  if  there  were  no  breath,'  but  on  the  occasion  of  this  visit  was 
thick  and  toneless,  and  there  was  evidently  an  obstruction  to  free  nasal  respiration.  The 
special  senses  of  hearing,  smell,  and  taste  were  unaffected.  Examination  of  the  anterior 
nostrils  failed  to  reveal,  as  was  suspected,  any  evidence  of  a  nasal  polypus.  On  attempt- 
ing rhinoscopy  and  laryngoscopy,  a  large  tumour  was  seen  to  project  from  the  posterior 
pharyngeal  wall.  On  digital  examination,  it  was  felt  to  be  hard  and  circumscribed.  It 
was  as  large,  and  extended  about  as  far  forward,  as  half  a  moderate-sized  orange. 

On  externally  examining  the  back  of  the  head,  it  was  at  once  seen  that  there  was  ar 
aiii^ular  curvature  forwards  of  the  cervical  portion  of  the  spine,  the  vertebrae  implicated 
being  the  second,  third,  ourth,  and  fifth.  The  spine  of  the  sixth  could  be  distinctly  felt. 
The  patient  explained  that  he  had  always  had  this  curvature,  but  had  suffered  no  incon- 
venience until  after  an  attack  of  Indian  fever  some  years  previously,  since  which  it  had 
seemed  to  increase.  Immediate  temporary  relief  was  given  on  elevation  of  the  head,  by 
placing  one  hand  under  the  chin  and  the  other  under  the  occiput.  Consultation  was  held 
with  Mr.  William  Adams,  who  advised  a  support  which  should  diminish  the  pressure  ; 
this  instrument  was  accordingly  adjusted,  and  exercised  a  good  result.  The  explana- 
tion of  the  symptoms  in  this  case  is,  without  doubt,  decrease  of  intervertebral  substance,, 
and  possible  absorption  of  the  compressed  vertebrae,  caused  partly  by  debility  after  the 
Indian  fever  and  partly  by  an  excess  of  the  natural  tendency  of  the  head  to  sink  with 
advancing  years.  It  is  interesting  to  note  further  that  the  general  health  of  this  patient 
was  exceedingly  good,  and  that  he  was  constantly  and  actively  occupied,  from  philan- 
thropic motives,  in  life-boat  work  on  the  southern  coast. 

New  formations  in  the  lower  pharynx  are  rare  compared  to 
those  in  the  larynx,  though  fibromata,  chondromata',  and  osseous 
tumours  are  all  occasionally  met  with,  and  polypi  are  sometimes 
seen  to  descend  from  the  naso-pharynx.  Cohen  reports  that  he 
has  met  with  one  case  of  ordinary  papilloma  growing  from  the 
mucous  membrane  in  the  posterior  wall  of  the  pharynx.    I  have 


DEFORMITIES  AND  MORBID  GROWTHS  OF  THE  PHARYNX.  22() 


treated  many  cases  of  small  benign  tumours  of  the  soft  palate, 
principally  fibrous  and  sebaceous.  Malignant  growths  are  com- 
paratively infrequent  in  this  region.  When  occurring,  they  are 
generally  of  the  encephaloid  or  lympho-sarcomatous  variety. 
Syphilitic  outgrowths  from  the  posterior  wall,  or  from  the  pharyn- 
geal boundary  of  the  larynx,  are  by  no  means  uncommon. 

The  SYMPTOMS  are  those  affecting  respiration  and  articulation, 
but  especially  deglutition. 

Treatment  is  mainly  of  an  operative  character.  Where  the 
tumours  cannot  be  removed,  artificial  feeding  by  a  long  oesophageal 
tube  may  be  necessary. 

Foreign  Bodies,  such  as  too  large  pieces  of  food,  fragments  of 
bone  from  fish  and  game,  artificial  teeth,  coins,  etc.,  may  lodge  in 
the  pharynx  and  give  rise  to  great  distress,  and  if  not  to  be 
otherwise  dislodged  require  introduction  of  long  forceps  or  the 
instrument  described  at  page  141  (Fig.  CL).  Such  accidents  and 
their  treatment  do  not  require  further  consideration  in  these  pages, 
since  they  come  within  the  scope  of  treatises  on  general  surgery, 

REFERENCES  TO  AUTHORITIES. 


177 
17S 
178 

181 

181 

185 
187 


192 

192 

194 

200 
201 

202 

202 
203 
209 


NO. 


SoLis  Cohen. 

SCHECH. 

>> 

Beverley  Robinson. 

bosvvorth. 

Stoerk. 

BOKAI. 

Lefferts. 
Nelaton. 

Morell-Mackenzie. 

Isambert. 
Carl  Seiler. 

Ramon  de  la  Sota. 

Krishaber. 
Kaposl 

Moxon. 

Hutchinson. 
Morell-Mackenzie. 
John  N.  Mackenzie. 


title  of  work  referred  to. 


Op.  cit.,  p.  5. 
op.  cit.,  p.  95. 
Op.  cit.,  p.  loi. 

/  Transactions  of  Amer.  Laryngol,  Associa- 
\    Hon,  p.  II.  1884. 

/  Transactions  of  Amer.  Laryngol.  Associa- 
\    Hon,  p.  2.  1884. 

/ Krankheiten  des  Kehlkopfes,  p.  i66.  Stutt- 
\    gart,  1880. 

Jahrhich  fiir  Kinderheilkiinde,  1876. 

/  Transactions  of  Amer.  Laryngol.  Associa- 

\    tion,  p.  39.  1884. 

{Quoted  by  Roe  in  an  erudite  contribution 
to    Transactiotis  of  Amer.  Laryngol. 
Association,  p.  23     seq.  1884. 
( Diseases  of  the  Throat  and  Nose,  vol.  i.,  p. 
\    33.    London,  1880. 
/  Conferences  Cliniqttes  sur  les  Maladies  dit 
\    Larynx,  p.  106.    Paris,  1877. 
Op.  cit.,  p.  177. 

{Compte- Rendu  du  Congres  Internationale 
de  Laryngoiogie,  p.  24  et  seq.  Milan, 
1882. 

Quoted  by  Isambert.    Op.  cit.,  p.  121. 

/  Syphilis  der  Hatit  u.   d.  angreuzenden 

\    Schleimhaute,  etc.    Vienna,  1875. 

(Transactions  of  Pathological  Society  y 
\    vol.  xxvii.    London,  1876. 

(Transactions     of   Pathological    Society ^ 
\    vol.  xxvii.    London,  1876. 
Op.  cit.,  p.  94. 

/ Amer.  Journal  of  Medical  Sciences,  Oct., 
\  1880. 


230  DISEASES  OF  THE  THROAT  AND  NOSE. 


REFERENCES  TO  AUTHORITIES— ((T^^w/wz^^rt'). 


PAGE. 

NO. 

NAME. 

TITLE  of  work  REFERRED  TO. 

212 
213 
213 

214 
214 
214 
214 

216 

220 

222 
224 
226 
228 
228 

20 
21 
22 

23 

24 
25 
26 
27 

28 
29 

30 

31 

32 

33 
34 
35 

Igambert. 

Sir  James  Paget. 

Isambert. 

Fraenkel. 

Heinze. 

/  Guttmann  and^ 
\    lublinski.  / 

WiLLIGH. 

Browne  and  Grant. 

T?ri<  WOP  TIT 

Browne  and  Grant. 

Beverley  Robinson. 

Lennox  Browne. 
G.  Cecil  Dickson. 
Schech. 
SoLis  Cohen. 
Kingston  Fowler. 

Op.  cit.,  p.  169  et  seq. 

(  Transactions  of  Pathological  Society,  vol. 
\    xxvii.    London,  1876. 
Op.  cit.,  p.  2ig  et  seq. 

(Berliner    Klinische    Wochenschr.,  Nov. 
1  1876. 

^  Londoft  Medical  Record,  Jan.  and  Feb., 
I  1877. 

Die  Kehlkopfschwindsucht.    Leipzifj,  1 879. 

Le  Progres  Medical.    Paris,  Aout,  1 883. 

Prager  Viertel Jahrschrift.,  ii.  1 856. 
^Archives  of  Laryjigology,  vol.  ii.  New 
\    York,  1 88 1. 
Op.  cit. 
Op.  cit. 

j  Trajisactions  of  Amer.  Laryngol.  Associa- 

\     Hon,  p.  118.  1885. 

W.  Riding  Asyl.  Rep.,  vol.  v.,  p.  271.  1875. 

Brit.  Med.  Joiirn.,  p.  888,  May  2,  1885. 

Op.  cit.,  p.  192. 

Op.  cit.,  p.  206. 

Lancet.    Nov.  30,  1889. 

CHAPTER  X. 


DISEASES  OF  THE  UVULA. 

When  inflammation  or  ulceration  attacks  the  upper  part  of  the 
pharynx  and  fauces,  the  uvula  is  almost  always  involved.  It 
commonly  becomes  relaxed  as  a  sequel  of  one  or  more  previous 
attacks  of  sore  throat,  or  such  a  condition  may  be,  and  often  is, 
the  first  symptom  of  discomfort  in  this  situation,  and  appears  as 
the  result  of  a  low  state  of  the  general  system,  and  without  any 
history  of  acute  angina.  In  such  a  case  the  relaxed  uvula  acts  as 
the  excitant,  or  at  any  rate  as  an  aggravator,  of  a  long  train  of 
most  inconvenient,  not  to  say  serious,  symptoms,  and  serves  td 
make  the  throat  pecuHarly  liable  to  catarrhal  attacks. 

That  this  is  so  may  be  proved  by  the  fact  that  all  efforts  to 
relieve  the  chronic  pharyngitis  will  often  prove  unavailing  so 
long  as  the  elongated  uvula  is  allowed  to  remain  intact ;  while,  on 
the  other  hand,  the  simple  removal  of  the  relaxed  tissue  will  as 
frequently  prove  efficacious  without  the  employment  of  any  other 
remedial  measure.  No  further  justification  is  therefore  necessary 
for  considering  diseases  of  the  uvula  under  a  separate  heading. 

ACUTE  INFLAMMATION  OF  THE  UVULA— CEDEMA  OF  THE 
UVULA  (Fig.  28,  Plate  IV.,  and  Fig.  36,  Plate  V). 

This  is  rarely  seen  except  as  associated  with  general  pharyn- 
gitis ;  but  now  and  again  cases  come  under  observation  in  which 
the  uvula  suddenly  becomes  red,  swollen,  and  infiltrated,  with 
comparatively  little  hyperaemia  of  the  neighbouring  parts. 

This  acute  inflammation  of  the  uvula  partakes  of  the  nature  of 
tonsillitis,  and  occurs  in  people  of  an  arthritic  diathesis ;  the 
bowels  are  constipated,  and  the  digestive  system  deranged. 
CEdema  of  the  uvula  is  also  not  uncommonly  seen  in  tertiary 
syphilis,  in  phthisis,  and  in  cases  of  general  hydrsemia.  Haemor- 
rhagic  extravasation  is  also  occasionally  witnessed  (Figs.  115 
and  116,  Plate  XIV.).    It  is  generally  of  traumatic  origin. 


232 


DISEASES  OF  THE  THROAT  AND  NOSh. 


The  SYMPTOMS  complained  of  are  those  of  obstruction  to  the 
respiration,  a  sense  of  discomfort  in  taking  food,  and  a  frequent 
desire  to  swallow  saliva,  with  but  little  acute  pain. 

Cough,  when  present,  is  of  an  irritating,  tickling  character,  and 
is  induced  in  those  cases  in  which  the  uvula  touches  the  epiglottis. 
It  is,  however,  often  absent  in  acute  oedema  when  the  enlarge- 
ment is  more  that  of  bulk  than  of  length. 

Treatment. — Removal  of  the  uvula  is  not  advisable  during  . 
acute  inflammation,  and  it  is  preferable  to  make  a  few  punctures 
and  scarifications,  followed  by  the  use  of  astringent  remedies.  In 
syphilitic  oedema  the  uvula  should  on  no  account  be  ablated. 

SUBACUTE  AND  CHRONIC  INFLAMMATION  OF  THE  UVULA 
(Fig.  13,  Plate  II.). 

This  is  seldom  seen  unassociated  with  a  certain  amount  of 
chronic  pharyngitis,  which  is  more  often  limited  to  the  pillars  of 
the  fauces,  without  any  extension  to  the  velum.  Chronic  inflam- 
mation leads  to  the  next  affection  : 

ELONGATED  UVULA— CHRONIC  RELAXED  THROAT  (Figs.  13  and 
14,  Plate  II. ;  Figs.  29  and  32,  Plate  IV.). 

This  condition  is  met  with  in  all  classes  of  patients  suffering 
from  chronic  angina,  but  especially  in  those  who  have  been 
obliged  to  use  the  voice  during  catarrhal  attacks — ^just,  in  fact,  in 
those  who  have  been  described  as  most  subject  to  chronic  pharyn- 
gitis (p.  192).  Very  few  people  suffering  from  that  disease  have 
not  a  relaxed  uvula ;  but  this  last-named  condition  often  gives 
rise  to  symptoms  which  demand  treatment  quite  irrespective  of 
the  rest  of  the  pharynx. 

Symptoms:  A.  Functional. — These  vary  greatly  in  different 
cases,  and  often  require  the  nicest  judgment  for  their  discrimina- 
tion. 

Thus,  while  one  patient  with  an  evidently  very  pendulous  uvula 
will  not  complain  of  any  inconvenience,  another  with  apparently 
but  slight  local  cause  will  exhibit  well-marked  symptoms.  The 
usual  sensation  is  that  of  a  desire  to  frequently  clear  the  throat  of 
a  source  of  irritation  ;  this  desire  being  only  experienced  at  par- 
ticular periods — as,  for  instance,  on  rising  in  the  morning,  on 
coming  into  a  warm  out  of  a  cold  atmosphere,  and  also  when  the 
general  system  is  fatigued  or  disturbed.  In  more  severe  cases 
there  will,  under  similar  circumstances,  be  hacking,  irritable 


ELONGATED  UVULA, 


233 


cough,  with  expectoration  of  small  muco-gelatinous  pellets, 
paroxysmal  and  spasmodic  attacks,  retching,  and  vomiting.  I 
have  seen  several  cases  in  which  the  last-named  symptom 
occurred  on  the  patient  taking  the  ordinary  morning  cold  bath, 
and  in  one  instance  the  breakfast  had  been  daily  rejected  for 
many  weeks.  In  another  case,  gargling  after  cleansing  of  the 
teeth  was  always  followed  by  violent  spasm,  with  bloody  expecto- 
ration, clearly  traced  to  come  from  the  pharynx. 

When  the  uvula  is  very  relaxed,  the  greatest  discomfort  is  felt 
as  the  patient  lies  down  at  night ;  many  cases  occur  of  spasm  of 
the  glottis,  so  severe  as  to  awake  patients  from  sleep,  and  due  to 
reflex  irritation  from  this  cause. 

It  is  but  natural  that  symptoms  such  as  those  described  combine 
to  bring  the  patient  to  a  state  of  great  nervous  prostration ;  the 
want  of  sleep,  the  cough,  and  the  retching  will  produce  great 
weakness  and  even  emaciation,  and  the  patient  will  appear  to  be 
suffering  from  phthisis  or  grave  organic  disease ;  especially  will 
this  be  suspected  in  those  occasional  cases  in  which  there  is  an 
account  given  of  fixed  pain  at  some  point  in  the  chest,  which,  on 
examination,  is  found  to  be  only  another  effect  of  reflex  irritation. 

I  was  consulted  in  the  year  1873  by  a  medical  practitioner  who  complained  of  constant 
pain  in  the  left  sub-scapular  region,  with  irritable  cough,  loss  of  flesh,  and  impairment  of 
general  health  ;  on  the  recommendation  of  two  physicians,  eminent  in  chest  diseases,  he 
sold  his  practice,  but  he  entirely  recovered  his  health  after  the  removal  of  his  uvula,  and 
is  still  well  and  in  active  professional  work. 

Again,  Mr.  Low,  of  Burton-on-Trent,  in  the  year  1888,  brought  me  a  gentleman  of 
middle  ajie,  to  whom  a  most  alarming  opinion  had  been  triven  ;  and  letters  were  laid 
before  me  detailing  the  presence  of  tubercle  bacillus  in  his  sputa,  and  forming  a  most 
gloomy  prognosis.  Mr.  Low  had  all  along  attributed  his  symptoms  to  reflex  irritation  of 
an  elongated  uvula  and  its  consequences.  In  this  opinion  I  concurred,  and  after  simple 
surgical  treatment  the  patient  made  a  complete  recovery. 

Gastric  derangements  will  be  aggravated  by  the  presence  of  an 
elongated  uvula,  while,  on  the  other  hand,  the  symptoms  caused 
by  the  relaxed  palate  will  be  increased  by  anything  likely  to 
induce  or  increase  the  disorder  of  digestion. 

The  ill  effects  of  a  relaxed  uvula  on  the  voice,  especially  if 
exercised  in  singing,  are  very  marked.  Fatigue  and  pain  after 
functional  use,  loss  of  strength,  purity,  and  brilliancy  in  quality, 
of  steadiness  (tremolo),  and  even  of  range,  are  the  precursors  of 
hoarseness  and  entire  destruction  of  the  singing  voice.  To  the 
occurrence  of  such  serious  conditions  as  a  direct  result  of  relaxed 
uvula,  both  ^Mandl  and  ^Labus  have  testified.  The  latter  very 
properly  points  out  that  disorder  of  phonation  from  this  cause  is 
due  not  so  much  to  elongation  of  the  uvula  as  to  the  difficulty 


234 


DISEASES  OF  THE  THROAT  AND  NOSE. 


which,  on  account  of  its  relaxed  condition,  the  subject  experi- 
ences in  making  the  various  movements  of  the  soft  palate  which 
are  necessary  for  the  formation  of  different  sounds;  in  other 
words,  to  paresis  of  the  elevators  and  tensors. 

B.  Physical. — These  are  not  easily  mistaken,  if  the  surgeon 
will  bear  in  mind  the  following  suggestions  when  he  makes  an 
examination  of  a  relaxed  throat : 

1.  Direct  the  patient  to  open  the  mouth  without  taking  a 
breath,  and  the  relaxed  uvula,  which,  if  in  a  normal  condition, 
should  on  inspiration  be  retracted,  will  be  seen  to  be  lying  on  the 
tongue. 

2.  Should  the  palate  not  drop  by  the  patient  thus  holding  the 
breath,  direct  him  to  breathe  through  the  nostrils,  which  will 
have  the  result  of  relaxing  the  palate,  and  the  length  of  the  uvula 
can  be  estimated. 

3.  Let  the  patient  then  breathe  in  deeply  through  the  mouth 
or  strike  a  high  note,  and  it  will  be  seen  that  the  uvula  is  not 
entirely  drawn  up,  owing  to  paresis  of  the  tensor  palati,  or  that 
the  uvula  goes  up  in  wrinkles,  partly  from  the  same  cause,  and 
partly  from  the  excess  of  relaxed  tissue. 

4.  Remember  that  the  amount  of  relaxation  depends  on  the 
relation  which  the  length  of  the  uvula  bears  to  the  arch  of  the 
palate. 

5.  In  those  cases  in  which,  observing  all  these  precautions,  the 
uvula  does  not  appear  to  be  relaxed,  and  yet  there  is  no  other 
reasonable  cause  for  the  symptoms,  observe  carefully  the  edges  of 
the  curtain  of  the  soft  palate,  and  they  will  be  seen  to  be  thinned, 
white,  and  quite  translucent,  and  to  almost  flap  about  with 
respiratory  action  (Fig.  14,  Plate  II.). 

This  last  appearance  will  be  often  present  in  ordinary  cases 
of  otherwise  recognisable  relaxation  of  the  uvula,  so  that  it  is 
quite  possible  to  mark  the  boundary  of  membranous  over-growth 
(Fig.  29,  Plate  IV.).  There  is  often  hypertrophy  of  the  lym- 
phoid glands  or  folHcles  in  the  tissue  of  the  uvula,  giving  the 
appearance  of  little  tubercles,  or  fatty  deposits  or  cysts.  Their 
presence  is  of  no  real  importance,  except  where  pain  is  experi- 
enced. These  little  bodies  may  then  be  real  tubercular  deposits, 
and  the  commencement  of  a  phthisical  ulceration.  Under  certain 
circumstances  they  may  indicate  an  early  stage  of  lupus. 

The  larynx  is  generally  slightly  congested ;  this  is  due  to  the 
constant  irritation  of  the  cough.  Mucus  may  often  be  seen  lying 
in  the  inter-arytenoid  fold.  The  veins  at  the  base  of  the  tongue 
are  often  concurrently  relaxed,  engorged  and  varicose,  and  the 
lingual  tonsil  hypertrophied. 


ELONGATED  UVULA, 


Treatment. — The  cause  having  been  ascertained,  it  must  be 
removed,  at  the  same  time  that  steps  are  taken  to  brace  up  the 
relaxed  mucous  membrane.  Astringent  lozenges  and  applications 
may  be  em.ployed  (Form.  12, 16,  and  17  ;  62  and  65).  These  failing, 
there  can  be  no  reason  w^hy  the  simple  operation  of  ablation  of 
the  relaxed  portion  should  not  be  performed  ;  on  general  grounds, 
however,  astringents  should  always  be  first  used,  since  it  is  advis- 
able to  see  how  much  of  the  relaxation  is  temporary  and  how 
much  permanent.  In  mild  cases,  particularly  when  associated 
with  dyspepsia,  attention  to  the  general  health  will  often  obviate 
altogether  necessity  for  abscission. 

In  operating,  the  uvula  should  always  be  well  drawn  out  with 
the  long  forceps  and  removed  just  above  the  point  of  junction  of 
the  mucous  membrane  wdth  the  body  of  the  uvula  (Fig.  CXIII.). 
Instruments  on  the  guillotine  principle,  called  uvulatomes,  are  not 


^"10.  CXIIT.— Uvula  Forceps  and  Uvula  Scissors,  in  Position  for  Operating. 


suitable  for  the  purpose  of  ablation  of  the  uvula.  The  tendency 
to  retraction  of  the  velum  when  touched  renders  it  very  uncertain 
how  much  will  be  removed  by  such  means.  The  parts  are  always 
bruised  and  crushed,  but  as  there  is  no  point  of  resistance  to  the 
instrument,  the  tissue  is  often  only  partially  separated.  An 
American  physician  informed  me  that  '  he  was  bound  to  say  that 


236 


DISEASES  OF  THE  THROAT  AND  NOSE. 


he  had  never  used  an  uvulatome  without  being  obhged  to  finish 
the  operation  with  scissors ;'  and  such,  it  is  beheved,  will  be  the 
general  experience  of  all  who  employ  this  instrument.  Nor  is  it 
advisable  to  make,  for  many  days  previously  to  removal,  lines 
around  the  uvula  with  caustic  pastes.  No  real  death  of  the  part 
takes  place,  but  there  is  a  considerable  increase  of  inflammation 
around,  so  that  when  division  is  made,  both  the  operation  and 
the  healing  process  are  more  painful  and  recovery  more  tedious. 
There  is  also  a  greater  risk  of  secondary  haemorrhage.  In  cases 
where  the  uvula  is  very  thin,  and  also  where  the  patient  has  an 
objection  *  to  the  knife '  or  to  loss  of  blood,  I  am  now  in  the 
habit  of  removing  the  elongated  portion  by  means  of  the  galvano- 
cautery  used  at  a  good  bright  heat,  the  tissue  being  first  drawn 
out  by  the  forceps,  as  has  been  advised,  prior  to  division  by  scissors. 
In  all  circumstances  I  previously  apply  cocaine,  in  a  5  or  lo  per 
cent,  solution,  as  the  pain  of  this  quite  minor  procedure  is  really 
great  in  some  cases,  and  is  always  apprehended  by  the  patient. 
Where  there  is  varix  of  the  vessels  at  the  base  of  the  tongue  I 
destroy  them  with  the  cautery  point  at  the  same  time  as,  or 
rather  prior  to,  removal  of  the  uvula. 

While  it  is  better  to  take  off  too  much  than  too  httle,  cases  have 
certainly  occurred  in  which  too  complete  removal  of  the  uvula 
has  been  followed  by  long  persistent  pain  and  some  difficulty  in 
swallowing.  Inasmuch  as  there  already  exists  an  unreasonable 
amount  of  prejudice  against  the  surgical  measures  here  advocated, 
it  is  a  pity  that  anything  should  be  done  to  bring  disrepute  upon 
so  valuable  an  operation,  of  which  it  has  been  truly  written  ^that 
'while  hardly  any  slight  affection  of  the  throat  produces  such 
serious  symptoms  as  elongation  of  the  uvula,  it  is  equally  true 
that  there  is  no  slight  operation  that  gives  such  complete  and 
permanent  relief  as  removal  of  the  elongated  extremity.' 

Regarding  treatment  by  operation,  Mandl  has  also  well  said 
that  *  It  is  unfortunate  that  this  operation  should  encounter  very 
ill-founded  opposition  on  the  part  of  artists,  since  there  can  be  no 
doubt  of  its  happy  effect  on  the  voice  due  to  the  removal  of  a 
permanent  cause  of  irritation  in  those  cases  in  which  it  is 
indicated.' 

If  the  patient  be  directed,  after  the  operation,  to  sit  perfectly 
still  without  washing  the  mouth,  haemorrhage  but  seldom  happens 
- — never  when  the  cautery  is  employed,  unless  the  platinum  be  of 
more  than  red  heat ;  should  bleeding  occur,  the  sipping  of  a  few 
drachms  of  a  saturated  solution  of  tannin  (Form.  4)  will  speedily 
check  it.    Should  it  recur,  application  of  the  fluid  known  as 


ELONGATED  UVULA. 


237 


styp'tic  colloid — a  combination  of  collodion,  alcohol,  and  tannin 
— will  have  the  desired  effect  of  forming  a  more  firm  coagulum 
The  pain  of  the  operation  itself  is  generally  but  slight,  though 
sometimes  intense ;  the  amount  of  after-pain  is  likewise  very 
variable ;  more  or  less  discomfort  in  swallowing  is  experienced 
for  from  twenty -four  hours  to  a  week,  and  all  food  should 
therefore  be  soft  and  tepid.  With  sensitive  patients  I  recom- 
mend application  of  a  five  per  cent,  solution  of  cocaine  to  the 
cut  surface  prior  to  taking  food.  Where  there  is  pain  in  the  ears, 
drops  of  laudanum,  atropine,  or  cocaine  applied  on  wool  along  the 
external  auditory  meatus  are  serviceable.  Care  must  be  taken  to 
avoid  catching  cold ;  the  patient  should  stay  within  doors  for  a  day 
or  two,  and  the  voice  should  be  completely  rested.  One  other 
caution  is  necessary  with  reference  to  the  after-treatment  of  these 
affections  ;  viz.,  that,  as  in  all  other  cases  of  reflex  irritation,  some 
time  may  elapse  before  the  symptoms  disappear  after  the  cause 
has  been  removed.  Remembrance  of  this  fact  will  often  prevent 
disappointment  and  discouragement. 


MALFORMATIONS  AND  NEW  GROWTHS. 

The  uvula  may  be  asymmetrically  truncated,  bifurcated,  or 
even  absent,  as  the  result  of  an  arrested  development.  The 
accompanying  drawing  (Fig.  CXIV.)  represents  an  extreme  case 
in  which  a  congenitally  double  uvula  is  the  subiect  of  consider- 
able relaxation,  giving  rise  to  the  ordinary 
symptoms  of  discomfort.  It  occurred  in  a 
young  man,  set.  22,  the  patient  of  my  col- 
league. Dr.  Orwin.  The  hard  palate  was 
very  contracted  and  highly  arched,  but  no 
difficulty  had  been  experienced  in  either 
articulation  or  deglutition.  Removal  was  fol- 
lowed by  relief  of  all  disagreeable  symptoms,  Fig.  CXIV.  —  Congeni- 
1     -i.!-  •  ^  4.     u  4.U  u      J      TAiLY  Double  Uvula, 

and  with  improvement  to  both  speech  and     ^j^h  Relaxation. 

deglutition. 

Warty  growths,  not  necessarily  dependent  on  any  syphilitic 
history,  though  generally  found  in  patients  having  that  dyscrasia, 
are  not  unfrequently  found  growing  from  some  portion  of  the 
surface  of  the  uvula.  Benign  neo-plasms  do  not  as  a  rule  give 
rise  to  much  inconvenience ;  but  in  several  instances  which  have 
come  under  my  notice  the  growths  have  been  attached  by  a  very 
long  pedicle,  and  have  produced  violent  irritation  of  the  larynx 
and  spasmodic  cough. 


23S  DISEASES  OF  THE  THROAT  AND  NOSE, 


In  one  such  case  which  (Fig.  30,  Plate  IV.)  I  reported  to  the 
Medical  Society  of  London,  so  far  down  did  the  growth  hang, 
that  it  was  not  seen  until  a  laryngeal  mirror,  introduced  to 
examine  the  glottis,  pushed  it  up  into  view.  In  this  case,  removal 
was  followed  by  immediate  relief  of  distressing  and  even  urgent 
respiratory  symptoms,  with  constant  spasmodic  cough  ;  and  such 
is  the  treatment  to  be  generally  recommended. 

Angeiomatous  (vascular)  growths  have  also  been  reported  as 
arising  from  this  situation,  and  cases  have  come  under  my  notice, 
both  in  my  own  practice  and  that  of  my  colleagues.  They  have 
been  successfully  treated  by  galvano-cautery. 

I  have  never  seen  malignant  disease  of  the  uvula  arising  pri- 
marily in  that  situation,  but  twice  I  have  noticed  it  as  an  extension 
from  epithelioma  of  the  tonsil. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 


NO. 


NAME. 


TITLE  OF  WORK  REFERRED  TO. 


233 


2 


Mandl. 
Labus. 


Hygiene  de  la  Voix,  p.  16^  ei  seq.    Paris,  1S76. 
London  Medical  Record,  January  15,  1S81. 
I  Science  and  Practice  of  medicine^  6th  ediiion, 


236 


3 


AlTKEN. 


p.  884.    London,  1872. 


CHAPTER  XL 


DISEASES  OF  THE  FAUOIAL  TONSILS. 

The  regional  and  microscopic  anatomy  of  the  faucial  tonsil  has 
already  been  described  (p.  28),  but  for  the  readier  appreciation  of 
the  changes  it  may  undergo  in  disease,  it  will  be  well  to  consider 
its  structure  in  somewhat  more  minute  detail. 

Histologically,  the  tonsil  is  a  large  lymphatic  gland.  Like 
other  lymphatic  masses  situated  throughout  the  alimentary  canal, 
that  portion  of  the  gland  which  looks  towards  the  lumen  of  the 
tube  is  separated  only  by  a  few  layers  of  stratified  epithelium,  and 
by  a  thin  covering  of  submucous  tissue,  from  the  faucial  passage. 
This  free  inner  mucous  surface  of  the  gland  is  not  smooth,  but 
presents,  as  previously  mentioned,  from  twelve  to  eighteen  orifices. 
These  orifices  lead  to  recesses,  crypts,  or  lacunae  in  the  substance 
of  the  tonsil.  The  crypts  are  not  true  secreting  glands,  but  mere 
involutions  of  the  mucous  membrane,  in  every  way  identical  with 
similar  structures  situated  at  the  posterior  surface  of  the  tongue, 
and  accordingly  rather  of  the  nature  of  ducts,  or  '  reservoirs,'  for 
leucocytes.  Ranged  round  the  walls  of  the  crypts  are  a  large 
number  of  closely  aggregated  spherical  and  oval  lymph-follicles — 
the  leucocyte  manufacturing  centres.  It  is  of  these  latter,  together 
with  the  less  dense  lymphoid  tissue  by  which  they  are  surrounded, 
that  the  mass  of  the  tonsil  is  composed.  The  lymphoid  follicles 
are  made  up  of  a  fine  connective-tissue  reticulum,  in  the  meshes 
of  which  are  the  dividing  leucocytes ;  the  reticulum  becomes 
much  more  dense  at  the  circumferential  portion  of  the  follicle,  but 
the  capsule  thus  formed  is  sufficiently  permeable  to  allow  of  the 
emigration  of  leucocytes  from  the  interior.  Each  follicle  is  sur- 
rounded by  a  lymph  plexus,  or  sinus,  which,  however,  is  absent  on 
that  side  of  the  follicle  which  is  opposed  to  the  adjacent  mucous 
lining  of  the  crypt.  The  deep  surface  of  the  gland  is  embedded  in 
the  tissues  of  the  fauces,  and  is  immediately  in  contact  with  con- 
nective-tissue, this  latter  forming  a  peritonsillar  membrane  or 


240 


DISEASES  OF  THE  THROAT  AND  NOSE. 


capsule.  All  these  various  parts  are  well  illustrated  in  Fig.  CXV., 
the  drawing  for  which  was  kindly  made  for  me  by  William  Hill, 
when  Pathologist  to  the  Throat  and  Ear  Hospital.  The  lymph- 
foUicles  of  the  tonsil  differ  in  no  respect  histologically  from  those 
found  lower  down  in  the  alimentary  canal,  and  there  is  probability 
in  the  suggestion  of  ^Hingston  Fox  that  they  may  have  a  some- 
what analogous  function ;  he,  however,  thinks  that  the  purpose  of 
the  spongy  tonsils  is  to  absorb,  through  the  crypts,  the  excess  of 
saliva  which  is  constantly  being  secreted.  The  investigations  of 
Hill,  previously  alluded  to,  leave  little  doubt  but  that  the  various 
tonsils  are  leucocyte-secreting  organs,  and  one  is  almost  irre- 
sistibly led  to  accept  the  conclusion  that  the  leucocytes,  which 
pass  by  diapedesis  from  the  lymph  follicles  into  the  crypts,  act  as 
phagocytes,  or  *  scavengers,'  in  the  mouth  and  pharynx. 

The  tonsil  is  liable  to  undergo  the  same  pathological  changes  as 
other  lymphoid  structures.    The  adenoid  tissue  is  rarely  affected 


Fig.  CXV. — Section-  of  a  (Slightly)  Hypertrophied  Tonsil. 

E.  Stratified  epithelium  covering  the  surface  and  lining. 
L.  Lacunae  or  crypts. 

P.  Parenchyma,  the  adenoid  tissue  of  which  is  not  shown. 

F.  Lymph-follicles,  S.  Lymph-spaces  mechanically  voided  of  their  contents,  in  section. 
M.  Mucous  glands. 

C.  Capsule  or  peritonsillar  membrane,  trabeculae  of  which  pass  into  parenchyma. 


without  involving  the  mucous  membrane  also.  Acute  inflamma- 
tion (suppurative  and  non-suppurative),  subacute  and  chronic 
inflammation,  general  hypertrophy,  ulceration  (simple  and 
specific),  induration  and  malignant  degeneration,  are  conditions 
interesting  in  their  clinical  rather  than  histological  aspects. 

For  the  general  consideration  of  the  etiology  of  tonsillar  inflam- 


ACUTE  TONSILLITIS. 


241 


mation,  the  reader  is  referred  back  to  the  chapter  on  the  general 
etiology  and  pathology  of  throat  diseases.  The  idea  is  now 
gradually  gaining  ground  that  tonsillitis  is  nearly  always  in  asso- 
ciation with  abnormal  states  of  the  buccal  secretions,  as  first 
insisted  on  by  Kingston  Fox — the  most  common  form  of  conta- 
mination being  that  which  comes  under  the  head  of  septic.  Prob- 
ably nine  out  of  every  ten  cases  of  tonsillitis  are  associated  with 
the  growth  of  micro-organisms  in  the  mouth  and  throat — the 
buccal  secretions  are  thus  extrinsically  contaminated.  Under 
this  heading  we  must  include  ordinary  insanitary  and  hospital 
sore-throat,  together  with  the  tonsillitis  (whether  membranous  or 
not)  of  scarlet  fever,  diphtheria,  small-pox,  measles,  and  typhoid. 
It  was  long  believed  that  the  tonsillitis  associated  with  the  gouty 
and  rheumatic  diatheses,  as  well  as  that  due  to  exhaustion  and 
mental  fatigue,  and  that  occasioned  by  an  ordinary  catarrh,  were 
not  catching,  were  of  a  non-epidemic  form,  and  were  not,  there- 
fore, connected  with  the  presence  of  a  micro-organism.  Evidence, 
however,  has  been  brought  forward  to  show  that  acute  rheu- 
matism, and  especially  rheumatic  tonsillitis,  is  a  germ  disease  ; 
and  it  is  suggested  that  the  secretions  of  the  mouth  and  throat 
form  a  fertile  culture-ground  for  micro-organisms  when  the  buccal 
secretions  are  intrinsically  contaminated  by  the  salivary  and  oral 
glands  acting  as  extraordinary  channels  of  excretion  in  catarrhal 
and  diathetic  states  of  the  system.  In  the  recent  discussion  on 
tonsillitis  at  the  Leeds  meeting  of  the  British  Medical  Association, 
Kingston  Fox  and  A.  Garrod  insisted  strongly  on  the  association 
with  micro-organisms  of  most  forms  of  acute  and  subacute  tonsil- 
litis, including  the  rheumatic  variety.  These  facts  will  readily 
explain  the  impossibility  that  all  practitioners  must  have  often 
experienced  of  differentiating  a  'septic'  from  a  'rheumatic'  ton- 
sillitis, and,  indeed,  they  go  far  to  support  the  opinions  of  those 
who  hold  that  acute  rheumatism  is  a  microbic  disease,  though  not 
necessarily  associated  with  a  single  specific  organism. 

ACUTE  TONSILLITIS,  AMYGDALITIS,  ANGINA  TONSILLARIS, 
ACUTE  INFLAMMATION  OF  THE  TONSILS,  QUINSY  (Fig.  31, 
Plate  IV.,  and  Fig.  36,  Plate  V.). 

The  mucous  covering  of  the  tonsils  may  partake  of  any  of  the 
general  inflammations  attacking  the  pharynx  and  fauces,  but,  as 
usually  understood,  the  term  *  quinsy '  implies  acute  inflammation 
limited  to,  or  at  least  originating  in,  the  parenchyma  of  the  glands 
themselves.    Several  distinctions  have  been  made  in  this  affec- 

16 


242 


DISEASES  OF  THE  THROAT  AND  NOSE. 


tion,  but  for  practical  purposes  they  are  mainly  differences  in 
amount  and  in  degree  ;  thus  only  the  mucous  surface  and  the 
orifices  of  the  crypts  or  lacunae  may  be  inflamed  {superficial  ton- 
sillar angina),  or  only  a  few  crypts  may  be  attacked  by  inflamma- 
tion and  their  function  arrested  without  involving  the  adenoid 
tissue  (lacunar  tonsillitis,  the  so-called  follicular  catarrh  of  the  tonsils), 
or  the  whole  gland-structure  of  the  tonsils  may  be  involved  {paren- 
chymatous tonsillitis).  This  stage,  when  proceeding  to  suppuration, 
is  in  turn  termed  tonsillar  abscess,  and  by  some  authors  the  term 
*  quinsy '  is,  without  philological  reason,  reserved  for  this  suppura- 
tive stage.  While  on  this  question  of  nomenclature,  I  may  express 
a  hope  that,  before  long,  the  erroneous  term  of  follicular  tonsillitis, 
still  more  ignorantly  termed  *  ulcerated  sore  throat,'  may  be 
abolished,  for  these  names  have  been  applied  to  a  condition  in 
which  the  lymphoid  folhcles  are  by  no  means  necessarily  involved, 
and  in  which  there  is  no  ulceration.  The  term  lacunar  was 
adopted  by  me  some  years  ago  as  accurately  representing  the 
anatomical  situation  of  the  morbid  condition.  It  has  since  been 
pointed  out  to  me  that  it  had  been  previously  proposed  by 
Wagner.  So-called  peritonsillitis,  in  which  the  inflammation  is  of 
the  connective-tissue  around  the  gland,  often  occurs  as  a  result 
of  a  low  state  of  health,  which  may  be  the  exciting  cause.  In 
m.y  experience  this  variety  is  generally  associated  with  septic 
conditions  of  drinking-water  or  residential  surroundings.  There 
is,  however,  frequently  superadded  the  special  diathesis,  to  be 
presently  considered,  as  almost  invariably  present  in  the  subjects 
of  both  the  lacunar  and  parenchymatous  forms. 

The  inflammation  may  subside  without  proceeding  to  sup- 
puration ;  it  may  be  superficial  and  limited,  or  deep  and  general. 
In  giving  a  description  of  this  disease,  therefore,  it  need  only  be 
hinted  that  all  the  symptoms  and  signs  may  not  be  present  in 
every  case  in  actual  practice,  or,  if  present,  many  of  them  may 
be  considerably  modified. 

Etiology. — Among  the  most  common  predisposing  causes 
assigned  by  various  writers  has  been  a  strumous  constitution, 
rendering  the  patient  liable  to  inflammatory  attacks  similar  to 
those  so  frequently  seen  in  the  lymphatic  glands.  This  view  has, 
however,  always  required  the  qualifying  admission  that  in 
tonsillitis  exposure  to  cold  is  an  exciting  cause,  whereas  catarrh 
plays  no  important  part  in  the  production  of  ordinary  strumous 
glandular  affections. 

From  most  careful  examinations,  extending  over  a  number  of 
years,  I  have  long  been  of  the  opinion  that  the  darthous  or 


ACUTE  TONSILLITIS. 


243 


arthritic  diathesis  invariably  exists  in  those  patients  subject  to 
recurrent  attacks  of  acute  tonsillitis.  There  need  not  necessarily 
be,  though  there  very  often  is,  corroborative  evidence,  either  in 
the  family  or  personal  history  of  the  patient ;  but  it  is  certain 
that  attacks  of  quinsy  are  most  prevalent  at  those  periods  of 
the  year  and  under  those  atmospheric  conditions  which  are  most 
favourable  to  rheumatic  exacerbations,  viz.,  in  early  spring  and 
the  later  months  of  autumn,  when  cold  damp  weather  with  south- 
east winds  is  prevalent. 

Indeed,  so  close  is  the  relationship  between  tonsiUitis  and 
rheumatism,  that  in  order  to  complete  the  picture  of  the  etiology 
of  the  former  affection  one  cannot  do  better  than  quote  almost 
verbatim  the  concise  account  of  the  predisposing  and  exciting 
causes  of  acute  rheumatism  given  by  ^F.  T.  Roberts,  merely 
changing  the  name  of  the  disease  : 

*  Predisposing  Causes. — Tonsillitis  is  distinctly  an  hereditary 
disease,  and  it  tends  to  run  in  families.  It  chiefly  attacks  persons 
from  fifteen  to  thirty-five  years  old,  being  especially  frequent  from 
sixteen  to  twenty,  but  no  age  is  exempt.'  It  is  rare  to  see  true 
lacunar  tonsillitis,  either  acute  or  chronic,  in  young  children, 
though  I  have  seen  a  typical  case  of  quinsy  in  a  young  girl  only 
ten  years  of  age  (Fig.  31,  Plate  IV.)  ;  and  ^Reid  has  recorded  a 
case  of  suppurative  tonsillitis  in  an  infant  aged  seven  months. 
It  is  most  common  between  the  ages  of  fifteen  to  thirty;  after 
thirty-five  it  is  rarely  seen,  though  cases  have  been  reported  up  to 
sixty,  and  one,  by  ^Whistler,  at  a  still  more  advanced  period  of 
life,  namely,  sixty-five.  I  have  recently  attended  a  young  lady, 
whose  father  informs  me  that  he  had  an  attack  of  true  quinsy 
when  seventy-one.  He  is  now  in  his  eighty-first  year.  *  Previous 
attacks  decidedly  increase  the  predisposition  to  the  disease. 
More  cases  are  met  with  among  males,  and  in  the  lower  classes, 
on  account  of  their  greater  exposure  to  the  exciting  causes. 
Climate  and  season  have  a  considerable  influence,  the  affection 
occurring  mainly  in  temperate  but  very  moist  climates,  and  where 
there  are  sudden  changes  of  temperature.  It  is  far  less  common 
in  tropical  and  very  cold  countries.  The  same  conditions  influence 
the  prevalence  of  the  complaint  at  different  seasons.  A  state  of 
ill-health  from  any  cause  is  said  to  predispose  to  tonsillitis,  and 
also  mental  depression  or  anxiety ;  but  many  individuals  are 
attacked  when  in  apparently  perfect  health.' 

*  Exciting  Causes. — The  ordinary  exciting  cause  is  a  sudden 
chill,  induced  by  exposure  to  cold  and  wet ;  sitting  in  a  draught 
when  heated  or  perspiring  ;  neglecting  to  change  wet  clothes,  or  in 


244 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Other  ways.  In  not  a  few  instances  no  definite  cause  can  be 
fixed  upon ;  and  it  is  quite  conceivable  that  processes  may  be 
gradually  carried  on  in  the  system  which  tend  to  generate  an 
amount  of  poison  sufficient  to  set  up  the  complaint.  Errors  in 
diet,  suppression  of  menses,  and  various  other  disturbances,  have 
been  ranked  as  causes.'  It  is  not  at  all  uncommon  to  see 
amenorrhoea  lead  in  the  same  patient  at  one  time  to  rheumatism, 
and  at  another  to  tonsillitis.  '  Scarlatina  seems  to  lead  to  ton- 
sillitis sometimes,  probably  by  interfering  with  the  excretory  func- 
tion of  the  skin  (and  gland).' 

When  many  years  ago  I  first  insisted  on  the  rheumatic  dia- 
thesis as  the  principal  etiological  factor  of  quinsy,  it  was  received 
in  some  quarters  with  ridicule,  and  by  many  as  an  exaggeration, 
but  since  then  the  same  idea  has  been  enunciated  as  quite  an 
original  view  by  more  than  one  writer.    ^Haig  Brown,  apparently 
ignorant  of  what  I  had  written,  has  truly  said  that  '  One  may 
do  more  than  merely  suggest  a  comparison,  and  say  that  the 
tonsillar   inflammation   is  sometimes  truly  rheumatic ;   or,  in 
other  words,  that  in  many  instances  the  cause  which  predis- 
poses to  the  development  of  tonsillitis  is  the  rheumatic  habit, 
while  the  cause   which  excites  the  inflammation  is  cold  and 
damp,  just  as  these  are  the  usual  determining  factors  in  arti- 
cular rheumatism.'    He  gives  statistical  evidence  of  the  most 
convincing    character   as   to   the   association   of  rheumatism 
and    tonsillitis,    mentioning    especially   the   occasional  mani- 
festations  of    a   cardiac   complication    during   an   attack  of 
quinsy.    Other  etiological  factors  of  tonsillitis  doubtless  exist, 
and  of  these  the  principal  is  that  of  a  septic  character.    To  this 
subject  the  author  just  quoted  has  devoted  much  attention.  The 
chief  septic  causes  of  tonsillitis  are  the  drinking  of  impure  water  or 
milk  diluted  with  impure  water,  and  the  exhalations  of  sewage- 
gas  ;  and  these  causes  will  act  more  powerfully  in  those  patients 
who  are  the  subjects  of  the  rheumatic  disposition.  Caution 
must  be  exercised  in  accepting  such  forms  of  tonsillitis  as  purely 
innocent,  and  especially  if  several  members  of  a  household  are 
attacked. 

It  remains  only  to  add  that  acute  inflammation  of  the  tonsils 
may  indifferently  attack  a  gland,  the  subject  of  chronic  enlarge- 
ment, or  one  which  is  of  normal  size  or  even  atrophied.  All 
tonsillar  inflammations  may  be  unilateral  or  bilateral,  and  not 
unfrequently,  disease  having  been  arrested,  or  having  subsided 
on  the  one  side,  is  developed  in  the  opposite.  I  entirely  concur 
in  the  opinion  of  *^  Kingston  Fox,  that  where  both  glands  are 


ACUTE  TONSILLITIS, 


245 


attacked  simultaneously,  the  inflammation  is  almost  invariably  of 
a  septic  nature,  and  this  circumstance  constitutes  a  valuable  diag- 
nostic sign.  In  all  cases  the  inflammation  is  liable  to  extend  to  the 
lymphatic  tissue  of  the  pillars  of  the  fauces,  and  to  the  soft  palate. 

Symptoms  :  A.  Functional. — Voice. — The  phonetic  quality  of 
the  voice  is  not  affected,  except  in  so  far  as  general  prostration 
may  diminish  its  power. 

Articulation  and  enunciation  are  greatly  impeded,  and  are 
quite  characteristic  in  the  obvious  pain  accompanying  the  acts 
and  in  the  complete  unintelligibility  of  the  speech ;  articulation  is 
affected  by  the  inflammatory  swelling  of  the  gland  and  of  the 
pillars  of  the  fauces ;  difficulty  of  enunciation  depends  largely  on 
impaired  mobility  of  the  jaw. 

Respiration. — The  free  passage  of  air  to  the  lungs  is  impeded, 
and  nasal  breathing  is  almost  entirely  obstructed,  the  patient 
snoring  loudly  even  when  awake. 

Cough. — None ;  but  a  frequent  desire  is  felt  to  clear  the  mouth 
and  back  of  the  pharynx  of  the  peculiar  and  abundant  viscid 
mucous  secretion. 

Deglutition  is  greatly  impeded  by  narrowing  of  the  faucial 
orifice  and  muscular  spasm,  and  is  accompanied  by  pain  of  a 
lancinating  character,  extending  to  the  temporo-maxillary  articula- 
tion. It  is  this  pain  which  prevents  the  patient  opening  the 
mouth,  and  also  causes  even  the  swallowing  of  saliva  to  be  dis- 
tressing. There  is  often  complete  inability  to  swallow  any  food, 
even  of  the  softest  consistence,  blandest  character,  and  mildest 
temperature ;  and  attempts  at  drinking  frequently  result  in  ejec- 
tion of  the  fluid  through  the  nostrils,  some  of  it  also  oozing  with 
saliva  and  mucus  from  the  angles  of  the  mouth. 

Hearing  is  often  temporarily  impaired,  with  not  infrequent 
pain,  due  to  extension  of  the  inflammation  to  the  middle  ear,  as 
well  as  to  irritation  of  the  chorda  tympani.  The  gravity  of  the 
aural  inflammation  varies,  and  is  seldom  severe ;  but  cases  of 
exudation,  serous  and  purulent,  into  the  tympanic  cavity,  are  by 
no  means  unknown.  In  many  instances  severe  tinnitus — usually 
of  the  pulsating  variety — is  complained  of. 

The  senses  of  Smell  and  Taste  are  both  greatly  affected ;  the 
latter  being  much  impaired  by  the  constant  presence  of  foul 
secretion  in  the  mouth. 

Pain  in  connection  with  functional  exercise  has  been  already 
aUuded  to;  but  it  is  a  constant,  ever-present  symptom  of  the 
disease,  and  the  one  element  which  appears  more  than  another  to 
produce  the  very  characteristic  prostration.    At  the  commence- 


246 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ment  of  an  attack  there  is  simply  a  feeling  of  dryness  and  heat ; 
but  as  the  affection  advances  the  swelling  of  the  parts  and  of  the 
surrounding  glands,  the  cramp  of  the  muscles,  with  ineffectual 
attempts  to  perform  functional  acts,  and  to  be  rid  of  oppressive 
obstruction,  all  tend  to  produce  a  sense  of  well-nigh  intolerable 
suffocation.  Pain  is  complained  of,  not  only  in  the  throat  and,  as 
before  mentioned,  in  the  ears,  but  in  the  temporo-maxillary 
articulation,  and  in  rotation  of  the  head,  which  is  often  held  quite 
stiff,  as  in  retro-pharyngeal  abscess.  Headache  is  also  a  constant 
and  wearying  symptom.  Painful  sensations  are  always  increased 
on  awakening  from  sleep. 

B.  Physical. — The  practised  observer  will,  if  the  disease  be  at 
all  advanced,  have  probably  arrived  at  a  correct  diagnosis  on 
hearing  and  seeing  the  patient's  attempts  to  describe  his 
symptoms ;  but  any  doubt  will  be  at  once  removed  when  he 
endeavours  to  examine  the  throat,  the  difficulty  of  opening  the 
mouth  being  almost  pathognomonic.  Should  he  succeed  in 
gaining  a  view  of  the  fauces,  he  will  see,  behind  an  overloaded 
foul  tongue,  a  more  or  less  uniformly  red  and  swollen  mucous 
membrane.  The  affected  tonsil  or  tonsils  (most  frequently  only 
one  is  attacked  at  first ;  or  one  is  in  a  much  more  advanced  stage 
of  inflammation  than  the  other)  will  be  seen  heightened  in  colour, 
and  enlarged  in  size,  causing  great  narrowing,  or  complete  closure, 
of  the  faucial  orifice.  Sometimes  the  cr3^pts  will  be  observed  to  be 
blocked  by  arrested  excretion,  or  covered  by  a  foul,  creamy  ex- 
udation. The  uvula,  which  may  partake  of  the  inflammation, 
and  be  oedematous,  will  more  often,  in  non-septic  cases,  be  seen 
relaxed,  and  will  be  lying  adherent,  as  it  were,  to  one  or  other 
tonsil.  The  pillars  of  the  fauces  are  not  always  inflamed,  but  the 
anterior  ones  are  more  often  involved  than  the  posterior.  The 
inflammation  rarely  extends  to  the  pharynx,  and  still  more  seldom 
to  the  buccal  cavity,  or  mouth.  In  patients  predisposed  to  quinsy, 
and  whose  tonsils  have  been  removed,  subsequent  recurrence  may 
attack  the  fauces.  It  is,  however,  very  rarely  that  the  process  in 
such  a  case  goes  the  whole  length  of  suppuration. 

When  visual  inspection  is  impossible,  it  may  be  desirable  to 
examine  with  the  finger,  so  as  to  ascertain  whether  suppuration 
has  taken  place ;  but  such  a  procedure  should  be  adopted  with 
hesitation,  as  it  always  occasions  increase  of  the  pain. 

C.  Miscellaneous. — In  these,  as  in  the  causes,  there  will  be 
noticed  a  great  analogy  to  rheumatism.  The  general  system  is 
greatly  disturbed,  the  patient  being  really  iU.  Frequently  the 
disease  commences  quite  suddenly,  but  more  often  there  is  a 


ACUTE  TONSILLITIS. 


?47 


warning  of  a  day  or  two.  In  hospital  practice  patients  seldom 
apply  until  they  have  been  ill  three  or  four  days,  *  thinking  the 
attack  would  pass  off.' 

At  the  commencement  the  ordinary  febrile  symptoms  of  inflam- 
mation are  present,  viz.,  heat  of  skin,  nausea,  thirst,  etc.,  with 
nocturnal  exacerbation ;  frequently  there  is  the  warning  of  a 
rigor;  this  stage  is  soon  succeeded  by  profuse,  cold,  sour  perspira- 
tion, with  pallor  of  surface,  anxious  expression  of  countenance,  and 
mental  depression,  greatly  increased  by  want  of  sleep,  and  occa- 
sionally resulting  in  delirious  wandering.  The  tongue  is  coated,  the 
breath  foul;  appetite  is  lost,  and  thirst  is  constant.  The  tem- 
perature is  greatly  increased,  averaging  103°  F.,  but  sometimes 
rising  to  104°  and  105°,  the  pulse  being  correspondingly  accelerated. 

Obstinate  constipation  invariably  precedes  and  accompanies 
the  disease;  the  urine  is  high-coloured,  and  loaded  with  excess 
of  urea  and  urates,  and  deficient  in  chlorides  ;  occasionally  there 
is  presence  of  albumen.  Dr.  Haig  Brown  has  noted  *  that  the 
existence  of  albumen  in  the  urine  seems  to  be  in  direct  ratio  to 
the  height  of  the  temperature.  When  this  is  over  103°  a  trace  of 
albumen  is  often  present ;  but  there  are  no  casts,  and  the  albumen 
always  disappears  when  the  temperature  begins  to  fall.  Its 
presence  is  of  no  more  importance  than  is  the  transient  albumi- 
nuria of  pneumonia  and  erysipelas,  though  on  first  finding  it  one 
is  apt  to  feel  a  httle  uncertainty  as  to  whether  the  throat  affection 
is  not  of  a  diphtheritic  nature.  Yet  it  is  important  to  note  the 
time  of  its  appearance — if  it  do  appear — and  of  its  disappearance, 
and  for  these  reasons :  if  albumen  be  found  for  the  first  time  on 
the  second  or  third  day,  the  temperature  being  at  103°  F.,  or  more, 
and  disappears  on  the  fourth,  we  are  almost  surely  dealing  with  a 
case  of  simple  tonsillitis ;  if,  however,  we  find  albumen  in  the 
early  days,  with  a  comparatively  low  temperature  (100°  or  101°)^ 
and  especially  if  the  albumen  persist  for  two  or  three  weeks, 
the  case  is  most  likely  one  of  diphtheria ;  while,  if  there  have 
been  no  albumen  early,  and  it  be  found  for  the  first  time  after  the 
end  of  two,  three,  or  more  weeks,  it  is  most  probable  that  the^ase 
has  been  one  of  latent  scarlatina.' 

It  is  always  well  to  examine  the  heart,  as  occasionally  a  bruit 
is  the  only  possible  indication  of  the  rheumatic  character  of  the 
tonsillitis.  In  recent  years  I  have  often  been  amazed  to  detect 
heart-murmurs  in  simple  subacute  tonsillar  inflammations. 

Externally,  except  where  there  is  suspicion  of  diphtheritic  or 
scarlatinal  origin,  there  is  seldom  sufficient  glandular  enlargement 
to  account  for  the  pains  and  stiffness  in  the  lower  jaw,  but  there  is 


248 


DISEASES  OF  THE  THROAT  AND  NOSE. 


sometimes,  in  severe  cases,  painful  puffiness  of  the  tissues  of  the  face 
and  neck.  Very  frequently  there  are  associated  rheumatic  articular 
and  muscular  pains  in  the  limbs,  and  in  many  cases  in  which  the 
disease  does  not  reach  suppuration,  resolution  of  the  local  trouble 
is  followed  by  a  smart  attack  of  rheumatism,  or  rheumatic  gout. 

Differential  Diagnosis. — The  diseases  that  may  be  con- 
founded with  tonsillitis  are  diphtheria,  phlegmonous  pharyngitis, 
scarlatina — where  the  rash  is  ill-developed — syphilis,  cancer,  post- 
diphtheritic and  labio-glosso-laryngeal  paralysis. 

From  diphtheria  it  may  be  differentiated  by  variation  in  many 
of  the  subjective  and  general  symptoms,  into  which  it  is  needless 
here  to  enter.  Especial  points  of  distinction  are  the  ease  with 
which  the  fauces  can  be  examined  in  diphtheria,  and  the  fact 
that  the  secretion  in  tonsillitis  is  limited  to  the  tonsils  themselves, 
is  non-adherent,  and  does  not  lay  bare  a  bleeding  or  ulcerated 
surface  when  removed :  whereas  it  is  most  rare,  when  diphtheria 
attacks  the  pharynx,  not  to  see  patches,  which  are  firmly  adherent, 
on  the  uvula  and  soft  palate.  Cases  are  now  and  again  seen  in 
which  diphtheria  follows  on  an  attack  of  tonsillitis  ;  in  such  an  event 
the  inflammation  is  exhibited,  as  is  the  diphtheria  itself,  on  both 
tonsils  equally.  A  bilateral  tonsillar  inflammation  of  the  lacunar 
variety  not  unfrequentl}^  occurs  to  some  members  of  a  household, 
generally  the  elder  relatives  or  immediate  attendants,  in  which 
diphtheria  has  arisen.  Such  an  attack  may  not  go  to  the  length 
of  suppuration,  but  will  have  many  modified  points  of  resemblance 
to  the  more  serious  malady,  and  will  exhibit  several  of  its 
complications  and  sequelae.  These  septic  varieties  of  tonsillitis, 
which  are  often  highly  infectious,  may  arise  independently  of  co- 
existent evidence  of  diphtheria  epidemics ;  and  they  have  been 
thought  to  be  forms  of  sore  throat  intermediary  between  those  of 
diphtheria  and  scarlatina,  the  exudation  of  the  one  and  the 
exanthem  of  the  other  not  being  manifested,  but  the  neurosal  and 
renal  complications  being  often  exhibited.  The  diagnostic  facts 
just  quoted  regarding  presence  of  albumen  in  the  urine,  and  the 
different  signs  of  scarlatina,  to  be  presently  mentioned,  are  of 
value  in  deciding  the  innocent  or  septic  character  of  the  attack. 

In  the  sore  throat  of  scarlatina  the  local  differences  are  not  so 
well  marked,  but  both  tonsils  are  always  attacked  sim^ultaneously. 
The  hot,  dry  skin,  high  degree  of  pyrexia,  flushed  face,  and 
characteristic  enlargement  of  the  papillae  of  the  tongue,  even 
without  the  appearance  of  the  rash,  will  assist  in  marking  the 
distinction.  It  must  not  be  forgotten  that  in  some  rare  instances 
of  tonsillitis  there  is  a  slight  skin  eruption.    In  such  a  case  the 


ACUTE  TONSILLITIS, 


249 


erythema  may  be  due  either  to  rheumatism  or  to  septic  influence. 
On  the  other  hand,  it  must  equally  be  remembered  that  scarlatina 
is  not  always  followed  by  desquamation,  and  that  the  kidneys  are 
not  always  affected.  The  most  characteristic  point  of  diagnosis 
is  glandular  enlargement  at  the  angle  of  the  jaw  in  scarlatina, 
and  the  absence  of  such  a  symptom  in  simple  tonsillitis. 

Phlegmonous  Pharyngitis  is  often  treated  as  tonsillitis,  and  the 
two  diseases  are  indeed  considered  as  one  by  ^  Cohen,  who  uses 
the  two  terms  synonymously.  They  may  be  differentiated  by  the 
history,  by  the  marked  asthenia,  and  locally  by  the  fact  that  the 
peritonsillar  tissue  is  affected  rather  than  the  gland  itself  in 
phlegmonous  inflammation. 

Measles  and  German  Measles  are  often  complicated  with  sore 
throat,  bilateral  in  character,  but  very  rarely  accompanied  by 
tonsillar  inflammation. 

Syphilis. — On  first  consideration,  it  would  hardly  appear  that 
there  was  much  likelihood  of  a  mistake  being  made  between  this 
disease  and  acute  inflammation  of  the  tonsils ;  but  the  possibility 
of  error  would  not  be  suggested,  had  not  I  witnessed  examples  of 
it,  both  in  the  early  secondary  and  in  the  acute  tertiary  forms. 

The  tonsils  are  often  inflamed  as  part  of  the  process  of 
secondary  manifestations ;  but  a  careful  comparison  of  the 
symptoms,  as  described  in  these  pages,  especially  with  reference 
to  the  particular  characteristic  of  secondary  syphilis — symmetry  ; 
and  of  the  tertiary  form — destructive  ulceration,  will  enable  the 
practitioner  to  avoid  so  serious  a  mistake. 

Cancer. — In  the  distressing  and  rare  affection  of  primary 
cancer  of  the  tonsil  there  is  infiltration  and  enlargement  of  one 
gland  only  and  of  the  surrounding  lymphatics,  with  foetor  of  breath, 
foulness  of  tongue,  and  difficulty  of  swallowing,  which  might 
well  lead  to  an  error  of  diagnosis.  Here,  again,  a  correct  opinion 
will  most  often  be  arrived  at  by  care  in  noting  the  history  and 
general  symptoms.  Especially  will  it  be  remarked  that  the 
graver  disease  proceeds  with  slow  and  gradual  steps,  and  has 
probably  existed  for  some  weeks  before  advice  has  been  sought. 

In  both  post-diphtheritic  and  lahio-glosso-laryngeal  paralysis  the 
difficulty  in  opening  the  mouth,  the  thickness  of  speech,  similar 
to  that  noticed  in  quinsy,  the  dysphagia,  ejection  of  fluids  by 
the  nostril,  and  excess  of  salivary  and  mucous  secretion,  might 
all,  at  first  sight,  lead  to  an  erroneous  diagnosis.  Inquiry  into 
the  previous  history,  the  duration  of  symptoms,  and  physical 
examinations  will  clear  up  doubts. 

Duration  and  Prognosis. — An  attack  of  tonsillitis  seldom. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


lasts  more  than  a  week  ;  but  there  is  a  great  tendency  to  relapse, 
especially  if  the  patient  has  been  subjected  to  insanitary  influ- 
ences. One  tonsil  having  been  affected,  and  the  attack  having 
terminated  by  resolution,  the  opposite  gland  may,  a  few  days 
later,  become  inflamed,  and  proceed  the  whole  length  of  suppura- 
tion. Thus  the  illness  may  extend  to  two,  or  even  three  weeks. 
Gangrene  never  occurs  in  the  form  of  tonsiUitis  here  described. 
The  prognosis  as  to  recovery  is  almost  invariably  favourable,  and 
convalescence  is,  as  a  rule,  wonderfully  rapid. 

The  patient  must  be  warned  that  a  first  attack  is  but  too  often 
the  forerunner  of  others,  which  may  recur  with  almost  periodical 
regularity. 

Cases  of  death  from  quinsy  have  been  reported,  but  in  all 
probability  they  have  been  due  to  association  with  more  serious 
disease,  especially  with  exanthematous  affections,  in  which  the 
eruption  has  not  been  developed.  Very  rarely,  as  in  young 
children,  death  might  occur  from  inanition ;  but,  as  already 
pointed  out,  the  disease  is  not  frequent  much  before  puberty. 
There  is  the  possibility  also  of  death  from  haemorrhage  on  the 
bursting  of  an  abscess.  Extension  of  simple  tonsillar  inflammation, 
however  acute,  into  the  larynx  is  a  rare  complication. 

Treatment  :  General. — First  and  all-important  is  a  thorough 
clearance  of  the  primce  vice,  with  the  continuance  of  moderate 
purgation  throughout  the  whole  course  of  the  attack.  Resolution 
is  greatly  favoured  by  the  early  and  frequent  administration  of 
one-drop  doses  of  aconite  (Form.  86). 

Guaiacum  given  in  mixture,  as  first  advised  by  Sir  Thomas 
Watson,  or  in  the  form  of  lozenges  (Form.  21),  appears  to  act 
both  locally  and  constitutionally,  and  its  almost  specific  effect 
tends  to  strengthen  the  rheumatic  analogy.  On  this  same  ground 
the  renal  secretion  should  be  kept  alkaline  by  the  potash  ^alts 
(Form.  95).  In  my  earlier  edition  I  stated  that  I  had  lately  tried 
salicylic  acid  with  fair  results.  Since  that  time  I  have  had  increased 
experience  of  the  salicylic  treatment,  and  generally  adopt  it  as 
preferable  to  that  by  aconite — for  one  reason  that  it  is  of  greater 
activity  in  preventing  extension  of  the  rheumatic  process  to  either 
muscles  or  articulations  (Form.  g8). 

Where  there  is  an}^  depressing  influence,  iron  may  be  added  to 
the  saline  mixtures  (Form.  96) ;  with  the  salts  of  salicylic  acid 
I  generally  combine  cinchona.  On  recovery,  simple  vegetable 
bitters  with  alkalies  (Form.  97  and  100)  are  much  more  service- 
able than  the  stronger,  but  less  easily  assimilated,  tonics. 

Local. — Contrary  to  recognised  traditions,  the  use  neither  of 


ACUTE  TONSILLITIS. 


251 


steam  (except  with  Lee  s  instrument,  page  105)  nor  of  spray 
inhalations  is  recommended,  as  the  fatigue  they  cause  the  patient 
far  outweighs  any  benefit  to  be  derived  from  them. 

Ice,  again,  although  occasionally  grateful,  much  more  often 
aggravates  pain  and  cramp.  By  far  the  most  effective  and  agree- 
able of  all  local  measures  is  the  frequent  holding  in  the  mouth, 
with  mild  attempts  at  gargling  by  the  Von  Troeltsch  method 
(page  100),  of  warm  water  medicated  with  glycerine  of  carbolic  acid 
(i  to  40  or  60),  or  saHcyHc  acid  (i  to  100).  In  cases  of  naso-pharyn- 
geal  stoppage  and  accumulation  the  syringing  of  the  nostrils  with 
a  saline  solution  is  often  attended  with  marked  relief  (Form.  73, 
74,  75,  and  78).  Lemonade  made  from  the  fresh  fruit  and  with  a 
little  sugar,  taken  through  straws,  is  very  refreshing,  and  is  often  suc- 
cessful in  *  cutting  the  phlegm.'  Guaiacum  lozenges  are  service- 
able in  the  early  stages  in  producing  resolution,  but  are  only  weari- 
some and  useless  when  symptoms  of  suppuration  are  manifested. 
Amongst  recent  remedies,  the  direct  application  of  carbonate  of 
soda  in  powder,  lozenges,  sprays,  or  mouth-washes  in  strong  solu- 
tion of  the  same,  gives  speedy  relief,  especially  in  the  undoubtedly 
rheumatic  varieties.  Salicylate  of  soda  in  excess  of  alkali,  as  a 
mouth-wash,  and  menthol,  as  a  spray,  paint,  or  lozenges  are 
equally  serviceable  in  the  rheumatic  and  septic  varieties. 

Externally,  severe  counter-irritation,  leeching,  and  other  de- 
pletive measures,  are  to  be  condemned.  External  application  of 
a  stimulating  liniment  of  ammonia,  of  the  compound  mustard 
liniment,  or  of  the  iodine  hniment  (B.P.),  are,  if  employed  early, 
of  possible  service  in  assisting  resolution  of  the  local  inflammation. 
Linseed  poultices — the  earlier  ones  containing  a  small  proportion 
of  mustard — wet  compresses  of  linen  or  Iceland  moss,  if  not  of 
great  utility,  are  of  too  established  a  reputation  to  be  omitted 
from  -^numeration ;  many  patients  prefer  a  simple  warm  silk 
wrapper.  For  some  years  past  I  have  been  in  the  habit  of  com- 
mencing the  treatment  of  every  case  of  tonsillar  inflammation 
without  reference  to  its  variety  or  causation  by  the  application  of 
continuous  cold,  as  explained  at  page  116.  The  results  are  so 
satisfactory  in  procuring  prompt  and  appreciable  relief  of  the 
symptoms,  and  of  really  arresting  or  abbreviating  ihe  attack,  that 
this  measure  may  be  recommended  with  the  fullest  confidence  as 
one  never  to  be  neglected. 

The  question  of  the  time  for  surgical  interference  is  one  on 
which  considerable  difference  of  opinion  exists  ;  the  following  is 
the  practice  which  I  pursue  and  recommend : 

I.  Never  to  inflict  unnecessary  pain  by  useless  scarifications  on 
the  surface  of  a  tonsil  undergoing  general  inflammation. 


252 


DISEASES  OF  THE  THROAT  AND  NOSE, 


2.  Never  to  make  deep  incisions  unless  there  is  almost  certainty 
of  advanced  suppuration.  The  instrument  for  making  an  incision 
should  be  a  curved  pointed  bistoury  with  not  more  than  one  inch 
of  cutting  edge,  and  the  cut  should  be  made  from  without  in- 
wards, so  as  to  avoid  the  not  impossible  risk  of  injuring  the  artery. 

3.  To  recommend  removal,  on  subsidence  of  the  attack,  of  ton- 
sils chronically  enlarged  and  liable  to  quinsy. 

4.  To  remove  the  tonsils  as  soon  as  they  become  sufficiently 
enlarged  in  those  cases  of  recurrent  quinsy  in  which  there  is  not 
chronic  enlargement,  but  in  which  the  tonsil,  though  diseased,  is 
too  small  for  excision,  except  on  occurrence  of  the  acute  inflam- 
mation. By  this  means  the  present  attack  is  at  once  cut  short 
and  the  chance  of  further  recurrence  avoided. 

Prophylactic. — On  occurrence  of  tonsillitis  in  the  case  of 
children,  the  patient  should  at  once  be  isolated  until  the  nature  of 
the  case  is  clearly  ascertained;  and  with  all,  confinement  to  bed  is 
desirable,  but  steam-kettles  and  thick  curtains  and  screens  are 
unnecessary  and  depressing.  In  view  of  the  fear  of  general  rheu- 
matism supervening  on  the  throat  attack,  great  caution  is  to  be 
exercised  against  taking  a  chill  during  convalescence.  The  hints 
already  given  of  the  liability  to  recurrence,  and  of  the  predisposing 
causes,  will  sufficiently  indicate  the  necessity  of  cautioning  the 
patient  on  recovery,  on  all  matters  of  diet,  climate,  and  sanitary 
surroundings.  Sea-air  and  Continental  baths  certainly  help  to 
diminish  the  tendency  to  development  of  the  diathesis. 

Seeing  that  constipation  invariably  precedes  an  attack  of  quinsy, 
it  behoves  the  patient  to  pay  particular  attention  to  the  regular 
daily  action  of  the  bowels.  There  is  nothing  better  for  this  pur- 
pose than  the  natural  saline  aperient  waters — Karlsbad,  Frie- 
drichshalle,  Hunyadi  Janos,  Pullna,  etc. 

CHRONIC  INFLAMMATION  OF  THE  TONSILS  (Fig.  33,  Plate  IV.). 
—ENLARGED  TONSILS  (Fig.  32,  Plate  IV.). 

The  first-named  condition  may  result  as  the  remains  of  an 
acute  inflammation,  or  it  may  be  due  to  a  chronic  disease  of  the 
lacunae  of  the  gland,  tending  to  inflammation,  dilatation,  and 
obstruction  of  the  crypts,  with  hypertrophy  of  the  parenchyma. 
So-called  chronic  follicular  disease  of  the  gland — preferably  chronic 
lacunar  tonsillitis — does  not,  as  has  been  already  pointed  out, 
necessarily  imply  glandular  enlargement,  and  this  occasional 
absence  of  hypertrophy  is  the  reason  why  such  cases  are  so 
obstinate  of  cure.  More  usually,  enlarged  tonsils  are  caused  by 
an  indolent  catarrhal   inflammation,   occurring   principally  in 


CHRONIC  INFLAMMATION  OF  THE  TONSILS. 


253 


scrofulous  children,  leading  to  enlargement  and  more  or  less 
induration  ;  or  it  may  be  due  to  a  true  hypertrophy,  with  but 
very  little,  if  any,  inflammatory  deposit,  much  as  the  lymphatic 
glands  may  become  enlarged  without  going  the  length  of  inflam- 
mation and  disintegration.  As  a  rule,  disposition  to  all  tonsillar 
inflammation  decreases  with  advance  of  years  ;  but  I  have  met 
with  several  notable  exceptions. 

One  that  impressed  me  was  that  of  a  maiden  lady  of  middle  age,  seen  nearly  three 
years  ago  in  consultation  with  Dr.  Davy,  of  Walmer.  The  tonsils  were  not  enlarged,  but 
both,  particularly  the  left,  were  inflamed,  with  several  points  of  cryptic  obstruction,  and 
some  pain  in  swallowing  and  in  other  functional  acts  was  experienced.  An  alarming 
diagnosis  of  cancer,  with  a  prognosis  of  only  three  or,  at  most,  six  months  of  life,  had  been 
made :  but  I  had  little  hesitation  in  giving  a  much  more  favourable,  though  equally 
positive,  opinion.  On  learning  it,  Dr.  Davy  was  told  by  the  other  practitioner  in  question 
that  he  was  content  'for  time  to  be  the  arbiter  between  us.'  I,  however,  urged  yet 
another  consultation,  and  Dr.  George  Johnson  was  selected  by  the  patient.  His  opinion 
was  promptly  enunciated  as  confirmatory  of  mine.  Treatment  on  the  general  and  local 
principles  to  be  presently  detailed  was  adopted.  The  patient  very  soon  recovered, 
and  is  still  living  in  excellent  health. 

Symptoms  :  A.  Functional. — The  subjective  signs  of  chroni- 
cally enlarged  and  inflamed  tonsils  need  hardly  be  elaborately 
described,  since  the  physical  evidences  are  so  easy  of  detection. 

Voice  will  be  husky,  toneless,  and  easily  fatigued ;  when  there 
is  hypertrophy,  it  will  be  thick,  guttural,  or  nasal,  and  will 
generally  be  high-pitched. 

Articulation  will  also  be  interfered  with,  the  patient  speaking 
as  with  a  full  mouth,  and  having  great  difficulty  in  pronouncing 
palatal  consonants. 

Respiration  can  never  be  carried  on  healthily  where  the  tonsils 
are  diseased,  since  all  inspired  air  passes  over  an  unhealthy 
surface,  the  narrowed  naso-pharynx  leading  to  mouth-breathing. 
There  is  always  nasal  stenosis,  a  condition  aggravated  by  the 
almost  invariable  presence  in  children  and  adolescents,  and  even 
in  adults,  of  post-nasal  adenoid  growths. 

Where  enlargement  is  considerable,  the  lungs  are  never  fully 
aerated,  the  chest-walls  become  narrowed  and  the  breast-bone  is 
prominent ;  the  patient  is  torpid  and  lethargic,  and  is  very  liable 
to  attacks  of  pneumonic  congestion.  It  is  not  often  that  respira- 
tion is  impaired  to  the  extent  of  really  alarming  symptoms  of 
suffocation,  but 

one  such  case  has  been  recorded  by  ^  Wesley  Mills  as  having  occurred  in  a  child  three 
years  of  age.  The  attacks  generally  occurred  while  eating,  but  at  night  also  attacks  of 
coughing  and  suffocating  spasms  were  so  frequent  as  to  cause  alarm  lest  death  should  result. 

Nasal  respiration  is  generally  greatly  impeded  from  the  obstruc- 
tion, as  well  as  from  concurrent  hypertrophic  rhinitis  and  ade- 


254 


DISEASES  OF  THE  THROAT  AND  NOSE. 


noids,  which  cause  the  patient  to  snore  loudly  in  sleep,  to  awake 
with  a  dry  throat  and  mouth,  and  to  breathe  audibly  during  the 
day,  with  the  mouth  wide  open,  this  last  in  association  with 
aprosexia  giving  a  characteristically  stupid  expression  to  the  face. 
Attention  has  been  drawn  by  some  writers  to  the  flattening  of  the 
nasal  bones,  due  to  insufficient  dilatation  of  the  naso-pharyngeal 
space,  and  the  appearance  is  considered  by  them  distinctive : 
this  condition  is,  however,  often  observed  in  other  diseases  which 
cause  obstruction  in  the  nasal  passages.  The  alse  of  the  nose  are 
often  pinched  and  dimpled  from  disuse. 

Cough  is  not  a  common  symptom,  but  I  have  seen  a  few 
instances  of  severe  spasmodic  cough  sometimes  simulating  per- 
tussis due  to  reflex  irritation  from  enlarged  tonsils. 

One  very  remarkable  case  came  under  my  notice  in  December,  1876.  It  was  that  of  a 
little  boy,  aged  ten,  who  had  suffered  from  constant  'hemming'  of  the  throat  for  about 
twelve  months,  and  from  persistent  dry  barking  cough  Mdthout  expectoration,  very  similar 
to  that  known  as  hysterical,  for  the  last  six  weeks.  So  persistent  was  this  cough  that  it 
would  recur  in  the  intervals  of  eating  at  meal-times,  and  the  moment  he  awoke  at  night. 
The  little  patient  had  been  under  the  care  of  two  able  family  practitioners,  and  had  been 
treated  for  stomach-cough,  tooth-cough,  thread-worms,  and  every  other  conceivable  cause 
for  the  irritation,  all  without  the  slightest  benefit ;  the  boy  was  becoming  exhausted,  was 
losing  appetite  and  flesh  from  want  of  sleep  and  the  ever-present  distressing  cough.  On 
looking  into  his  mouth,  the  tonsils  were  seen  to  be  very  much  hypertrophied  ;  and  failing 
on  examination  to  find  any  other  abnormal  condition,  they  were,  with  the  consent  of  the 
father,  then  and  there  removed.  From  that  moment  the  child  lost  his  cough,  and  it  has 
not  since  returned. 

Two  almost  exactly  similar  cases  came  under  my  notice  in 
the  year  1886,  each  little  patient  being  the  child  of  a  medical 
confrere.  In  both  the  success  of  treatment  by  removal  of  the 
cause  was  as  complete  as  in  the  case  narrated.  Recent  experi- 
ence leads  me,  even  when  the  tonsils  are  not  much  enlarged,  to 
suspect  adenoid  growths  in  all  cases  of  reflex  spasmodic  cough. 

Deglutition  is  seldom  painful,  but  generally  uncomfortable, 
especially  on  the  slightest  recurrence  of  inflammation.  There  is 
unusual  sensitiveness  to  food  at  high  temperature  and  of  piquant 
character.  Another  characteristic  of  enlarged  tonsils  is  that  there 
is  a  desire  to  take  fluid  very  frequently  during  eating,  so  as  to 
assist  the  passage  of  solid  food  ;  and  there  is  often  a  difficulty, 
especially  with  young  children,  in  swallowing  any  but  the  most 
minutely  divided  portions. 

The  senses  of  hearing,  of  smell,  and  of  taste  are  all  more  or 
less  impaired.  One  very  common  cause  of  deafness  is  obstruc- 
tion of  the  Eustachian  tube,  due  to  enlarged  tonsils.  It  is  not, 
as  has  been  already  pointed  out,  that  the  enlarged  tonsils  them- 
selves obstruct  the  Eustachian  orifice,  but  there  is  usually,  with 
such  a  condition,  the  association  of  disordered  secretion  with 


CHRONIC  INFLAMMATION  OF  THE  TONSILS, 


255 


chronic  hypertrophic  inflammation  of  the  naso-pharynx,  and  a 
strong  tendency  for  the  catarrhal  inflammation  to  extend  to  the 
middle  ears.  In  these  cases  also  there  is  not  unfrequently  a 
disposition  for  the  cerumen  to  be  impacted. 

Pain  is  rarely  an  element  of  chronic  tonsillar  disease  or  of 
enlargement ;  but  ^Andrew  Smith  has  reported  a  case  of  neuralgia 
traceable  to  this  cause  and  cured  by  its  removal.  Subjective 
sensations  of  foreign  bodies  in  the  throat,  and  frequent  efforts  to 
dislodge  accumulation  of  mucus,  are  very  frequent. 

Mention  may  here  be  conveniently  made  of  painful  glandular 
enlargement  of  the  neck,  generally  one-sided,  w^hich  is  sometimes 
but  rarely  caused  by  the  presence  of  benign  hypertrophy  of  the 
tonsils.  I  have  seen  a  few  such  cases  in  which  reduction  of  the 
swelhng  following  tonsillotomy  has  confirmed  the  diagnosis. 

B.  Physical. — On  looking  into  the  throat,  the  cause  of  all  the 
foregoing  symptoms  is  at  once  apparent.  One  or  both  tonsils  are 
seen  to  be  more  or  less  enlarged  and  inflamed,  and  in  a  corre- 
sponding degree  to  obstruct  the  faucial  opening.  They  are  often 
studded  with  several  open  crypts,  some  of  them  filled  with  white 
or  yellowish-white  matter :  when  pressure  is  made,  this  matter  is- 
seen  to  exude  in  cheesy-looking  masses  of  very  offensive  odour. 
In  the  adult  these  open  and  inflamed  crypts  may  sometimes  be 
so  large  as  to  give  rise  to  a  doubt  as  to  the  non-syphilitic  nature 
of  the  disease.  A  careful  examination  revealing  other  lacunae  in 
a  less  advanced  state  of  inflammation  wiU  dispel  such  a  fear. 

C.  Miscellaneous.; — The  general  health,  as  has  been  indi- 
cated, may  greatly  suffer  from  such  a  cause ;  every  function  of 
circulation,  respiration,  and  digestion  being  performed  in  a  slug- 
gish manner,  nutrition  consequently  becomes  greatly  impaired. 
The  main  cause  of  deterioration  of  health  is  the  disturbance  of 
the  patient's  rest  at  night.  Sleep  in  the  earlier  hours  is  restless, 
and  often  broken  by  the  loud  snoring  which  will  even  awake  the 
subject  himself ;  but  towards  morning  the  sleep  is  very  heavy, 
and  the  patient  is  often  with  difficulty  aroused,  this  circumstance 
probably  arising  from  passive  congestion  of  the  lungs,  due  to 
obstructed  respiration  and  imperfect  aeration.  There  is  usually 
the  history  of  one  or  both  parents,  and  of  other  members  of  the 
family,  suffering,  or  having  suffered,  from  a  similar  tendency  to 
enlarged  tonsils,  and  the  diathesis  is  either  rheumatic  or  strumous. 

Treatment  of  chronic  lacunar  disease  is  very  tedious  and 
unsatisfactory  where  the  tonsils  are  not  hypertrophied.  It  has 
been  proposed  to  squeeze  out  the  cheesy  secretion  from  each 
diseased  crypt,  and  then  to  apply  solid  nitrate  of  silver  or  other 
caustics  —  preferably  the  galvano-cautery  if  available  —  to  the 


256 


DISEASES  OF  THE  THROAT  AND  NOSE. 


cavity.  Such  measures  are,  however,  but  too  frequently  only 
tentative,  and  not  of  permanent  benefit.  It  is  better  to  treat 
such  a  case  on  general  principles,  according  to  the  diathesis,  and 
to  give  guaiacum  or  chlorate  of  potash  lozenges.  Whenever  (as 
is  almost  certain  to  occur  in  these  cases)  active  inflammation 
causing  enlargement  takes  place,  it  is  to  be  rather  encouraged 
than  arrested,  and  the  gland  then  removed.  I  have  frequently 
pursued  this  plan  with  the  most  satisfactory  results.  In  other 
cases,  destruction  of  the  diseased  tissue  is  best  effected  by  appHca- 
tions  of  galvano-cautery,  repeated  as  required  at  intervals  of  a 
week. 

Chronic  enlargement  of  the  tonsils  is  only  to  be  treated  satis- 
factorily by  the  one  method  of  excision,  and  there  does  not  appear 
any  valid  reason  why  there  should  be  two  opinions  on  the  ques- 
tion.   The  operation  is  simple,  it  is  accompanied  with  little  pain  ; 


Fig.  CXVT. — Tonsil  Guillotine,  in  Position  for  Operating  on  the  Left 

Tonsil. 

the  result  is  speedily  and  almost  always  of  permanent  benefit.  All 
measures  of  local  applications,  *  removal  w^'thout  cutting '  by 
caustic  pastes,  injections  into  the  substance  of  the  gland,  are  use- 
less, and  some  of  them  barbarous.  This  last  objection  certainly 
does  not  obtain  in  the  case  of  electrolysis,  or  in  application  of  the 
continuous  current  without  needles ;  but  such  a  process  is  too 
tedious  and  troublesoijie  to  be  recommended  for  general  use. 

Excision  is  best  performed  with  a  guillotine  (Fig.  CXVL),  the 
patient's  head  being  held  by  an  assistant,  who,  standing  behind, 
at  the  same  time  presses  in  the  gland  from  without,  on  the  side  on 
which  the  surgeon  is  operating.  This  avoids  the  necessity  of 
employing  forceps.  So-called  double  guillotines,  constructed  to 
remove  both  tonsils  at  once,  like  most  instruments  that  attempt 
too  much,  often  fail  to  be  of  any  use  whatever.  When  it  is  re- 
quired to  remove  both  tonsils,  it  is  better,  having  excised  one,  to 


CHRONIC  INFLAMMATION  OF  THE  TONSILS, 


25/ 


withdraw  the  instrument,  dislodge  the  removed  gland,  and  to 
quickly  re-introduce  the  guillotine  on  the  opposite  side,  before  the 
patient  realizes  that  there  is  a  second  operation,  and  also  before 
haemorrhage  sets  in.  By  this  measure  one  operation  and  one 
sore  throat  only  are  necessary,  and 
the  risk  is  avoided  of  a  young  patient 
refusing  to  allow  of  a  repetition. 

Where  the  gland  is  very  large,  and 
especially  where  it  grovv^s  down  along 
the  side-wall  of  the  pharynx,  it  is  not 
always  possible  to  get  the  rigid  ring 
quite  round  the  tonsil.  In  such  a  case 
a  wire-loop  ecraseur  may  be  employed. 
The  instrument  here  depicted  (Fig. 
CXVII.)  answers  admirably  for  this 
purpose,  and  quite  obviates  all  risk  of 
hcemorrhage.  I  employed  the  galvano- 
cautery  loop  in  one  instance  of  this 
kind ;  but  found  that  while  there  was 
no  advantage  over  the  ordinary  ecra- 
seur, the  after-pain  of  the  eschar 
was  much  greater.  This  process  is 
not  therefore  to  be  recommended. 
Very  rarely  indeed  is  there  a  re- 
development of  the  hypertrophy ;  but 
as  such  a  circumstance  is  not  outside 
my  experience,  I  always  endeavour  to 
remove  as  much  of  the  gland  as  can 
be  pressed  into  the  guillotine,  and  I 
would  deprecate  the  advice  of  some 
surgeons,  that  the  removal  of  a  '  slice  ' 
off  the  tonsil  is  sufficient  to  ensure 
atrophy  of  the  rest.  Removal  is  made 
more  easy  if  a  guillotine  or  wire-loop  is 
chosen  rather  trnder  the  size  of  the 
gland,  which  is  thus  on  pressure  the 
more  completely  encircled  and  fixed 
before  the  cut  is  made. 

Regarding  the  question  of  haemor- 
rhage, I  can  but  say  that  it  has  been  most  rare  in  my  experience, 
and  I  have  only  seen  and  known  of  three  cases  in  my  own  practice 
and  that  of  colleagues  during  a  period  of  nearly  twenty  years,  in 
which  the  bleeding  has  been  serious,  and  only  one  in  which  it  was 

17 


258  DISEASES  OF  THE  THROAT  AND  NOSE. 

at  all  alarming.  Should  it  occur,  similar  treatment  to  that  recom- 
mended after  removal  of  the  uvula  is  to  be  adopted,  namely,  the 
sipping  of  a  saturated  solution  of  tannin  (Form.  4).  In  one 
instance  only  have  I  seen  this  measure  fail,  and  I  then  substituted 
with  success  the  *  Styptic  Colloid '  (see  page  221).  Occa- 
sionally secondary  haemorrhage  may  take  place  a  day  or  two  after 
removal,  but  it  is  easily  stopped.  The  most  troublesome  case  I 
ever  saw  was  brought  about  by  irritation  from  a  crumb  of  toast. 
All  food,  therefore,  for  a  day  or  two  must  be  soft  in  consistence 
and  of  mild  temperature.  In  another  instance — that  of  a  domestic 
servant — bleeding  occurred  on  the  third  day  after  removal,  while 
she  was  kneeling  and  cleaning  door-steps. 

i^Lefferts,  who  has  treated  this  subject  with  some  detail  and 
with  impartiality,  takes  a  more  serious  view  of  the  question ;  he 
thus  summarizes  his  experience  :  *  That  though  the  operation  of 
tonsillotomy,  thoroughly  performed,  is  usually  unattended  by  un- 
toward result,  still  it  is  not  entirely  free  from  alarming,  some- 
times dangerous  results  ;  and  that  though  these  be  the  exception 
they  should  not  be  ignored ;  and  that  the  surgeon  nmst  always  be 
prepared,  both  mentally  and  manualty,  to  cope  with  a  haemorrhage 
that  may  unexpectedly  occur.' 

The  measure  particularly  recommended  by  Lefferts  is  pressure 
within  the  mouth  and  counter-pressure  outside.  It  would  not 
be  right  to  omit  the  statement  that  extreme  cases  are  on  record 
in  which  the  haemorrhage  after  tonsillotomy  has  been  fatal, 
and  that  in  others  it  has  been  necessary  to  tie  the  common 
carotid.  It  has,  however,  to  be  borne  in  mind  that  in  all,  or 
almost  all,  these  serious  cases  the  bistoury  has  been  employed  in 
place  of  the  much  safer  guillotine.  It  is  quite  impossible  to 
determine  whether  excessive  haemorrhage,  when  it  occurs,  depends 
on  an  increased  vascularity,  due  to  the  general  hypertrophy,  to  an 
abnormally  superficial  distribution  of  the  tonsillar  artery,  or,  where 
a  bistoury  is  used,  to  a  wounding  of  this  vessel  at  its  anastomosis 
with  the  lingual.  In  view  of  the  possibility  of  any  of  these 
accidents — as  well  as  of  the  occurrence  of  other  avoidable 
sequelae,  due  to  insanitary  homes,  in  the  case  of  operations  on 
out-patients — it  has  for  some  years  been  a  rule  of  my  colleagues 
and  myself  to  insist,  wherever  feasible,  on  residence  for  a  few 
days  in  the  hospital,  or  with  private  patients  within  our  reach. 

It  may  be  asked,  *  Is  the  knife  or  guillotine  the  only  method  of 
reducing  the  size  of  enlarged  tonsils  ?'  This  brings  me,  therefore, 
to  the  measure  so  much  in  vogue  in  America,  of  galvano-cautery 
puncture.    l^Iy  general  objections  to  this  proceeding  are  stated  at 


ATROPHY  OF  THE  TONSILS. 


259 


length  in  the  section  on  galvano-cautery  (Chap.  VII.),  but  I 
entirely  agree  with  Knight  on  the  advisabihty  of  adopting  this 
method  on  any  patient  with  a  haemorrhagic  tendency. 

The  surgeon  is  often  asked,  '  Are  any  ill  effects  likely  to  take 
place  after  removal  of  the  tonsils  ?  Will  the  patient  be  more 
liable  to  suffer  from  cold,  or  to  contract  diseases  such  as  diph- 
theria ?  Will  the  voice  be  likely  to  suffer  ?'  To  all  such  questions 
most  positive  answers  may  be  given  that  nothing  but  ultimate 
good  can  follow  from  this  operation  in  suitable  cases. 

It  would,  perhaps,  hardly  be  credited  that  prejudice  still  exists 
against  this  operation,  from  a  belief  that  it  may  arrest  sexual 
development.  Such  an  ignorant  thought  was  suggested  to  the 
parents  of  one  of  my  patients,  after  the  operation,  by  a  homoeo- 
pathic practitioner;  and  the  subject  was  even  thought  worthy  of 
occupying  the  greater  portion  of  a  recent  sitting  (October,  1886) 
of  the  Chnical  Society  of  London.  It  is  not  necessary  to  confute 
this  remnant  of  tradition  with  serious  arg«ment,  but  it  is  interest- 
ing to  allude  to  the  fact  that  Chassaignac  pointed  out  that  while 
hypertrophy  of  the  tonsils  tends  to  arrest  sexual  development, 
their  removal  favours  it. 

ATROPHY  OF  THE  TONSILS. 

This  condition,  as  truly  stated  by  Wagner,  has  been  prac- 
tically but  httle  investigated.  In  justification  it  may  be  pleaded 
that  it  is  only  hypertrophy  for  which  the  surgeon's  aid  is  usually 
sought.  The  disease,  if  such  it  be,  is  admitted  to  be  often  only 
discovered  in  the  dead  subject ;  and  since  it  is  further  allowed 
that  *  many  observations  go  to  prove  that  persons  with  congenital 
or  acquired  atrophy  of  the  tonsils  are  less  subject  to  almost  all 
the  diseases  of  the  tonsils,  especially  the  ordinary  inflammation — 
diphtheritis  in  its  various  forms,  and  syphilis  ' — it  is  not  surpris- 
ing, nor  to  be  lamented,  that  '  clinically,  atrophy  of  the  tonsils 
has  received  but  little  attention.' 

Only  one  variety  described  by  Wagner  under  this  head  is  of 
interest — that  in  which  there  is  dilatation  and  blocking-up  of  the 
lacunae,  without  corresponding  adenoid  hypertrophy ;  but  this 
affection — known  to  English  surgeons  as  chronic  follicular  {lacunar) 
disease  of  the  tonsils — is  well  recognised,  and  has  already  received 
full  consideration  in  these  pages. 


26o 


DISEASES  OF  THE  THROAT  AND  NOSE. 


MYCOSIS  BUCCALIS  ET  TONSILLARIS. 

Excessive  fungoid  growths  in  the  mouth,  especially  in  the 
crypts  of  the  faucial  and  lingual  tonsils,  is  rather  rare  in  this 
country.  I  have  myself  seen  very  few  of  such  cases,  and  in  every 
instance  the  pathological  report  has  been  that  leptothrix  has  been 
the  prevaiHng  vegetable  parasite  present.  The  condition  presents 
many  features  similar  to  lacunar  tonsiUitis,  but  the  term  *  mycosis 
tonsillaris '  is  usually  given  to  any  exuberant  fungoid  growth 
which  not  only  blocks  the  crypts,  but  spreads  over  the  surface  of 
the  tonsils  and  base  of  the  tongue,  but  is  often  seen  on  the  gums 
and  teeth.  In  fact,  the  discharge  from  carious  teeth  is  probably 
the  pabulum  on  which  the  parasite,  normally  present  in  the  mouth, 
attains  such  enormous  development.  The  subjects  of  mycosis 
usually  inhabit  damp  insanitary  dwellings,  and  exhibit  want  of 
cleanliness. 

The  most  recent  case  in  my  experience  was  that  of  an  actress,  who  would  resent  with 
indignation  such  an  imputation,  but  who  was  in  the  habit  of  closing  the  pores  of  her  neck 
and  face  by  extreme  '  make  up,'  both  on  and  off  the  stage. 

Mycosis  predisposes  to  the  formation  of  tonsillar  and  probably  of 
salivary  calculi. 

The  Treatment  usually  adopted  is  to  destroy  the  parasite  by 
the  application  of  the  galvano-cautery  point  to  the  crypts  and  other 
spots  where  it  is  growing.  If  this  measure  is  not  adopted,  the 
spots  should  be  touched  with  glycerine  of  carbolic  acid,  with 
menthol,  or  with  chromic  acid.  Antiseptic  mouth-washes,  together 
with  attention  to  the  teeth  and  to  sanitation,  obviously  comprise 
the  after-treatment. 


BENIGN  GROWTHS  ON  THE  TONSILS. 

These  are  occasionally  seen.  They  are,  for  the  most  part, 
simple  hypertrophies  of  the  mucous  membrane,  which  have 
become  more  or  less  pedunculated  ;  often  they  take  their  origin 
at  the  mouth  of  a  lacuna,  which  appears  as  if  prolapsed.  They 
may  be  considered  supernumerary  tonsils  in  some  instances. 

They  offer  no  special  points  calling  for  particular  remark ;  but 
if  they  occasion  annoyance,  a  simple  remedy  is  found  in  their 
ablation. 

Calcareous  concretions  are  not  unfrequently  developed  in  the 


BENIGN  GROWTHS  ON  THE  TONSILS. 


261 


crypts  of  the  tonsils,  whence  they  are  extruded  or  require  to  be 
removed.  They  were  until  lately  considered  as  due  to  degenera- 
tion of  the  arrested  lacunar  exudation;  but  ^^Gruening  has  stated 
that  all  tonsillar  concretions  and  pharyngeal 
concretions  are  of  parasitic  origin,  and  are 
composed  of  leptothrix  elements  ;  and  that  the 
microscopic  features  and  chemical  reactions 
of  the  tonsillar  concretions  are  identical  with 

those  observed  in  the  concretions  occurring  Fig.    cxvill.— Cal- 
^1    ,   ,1  •  •        r  .^  cAREOus  Formation 

m  carious  teeth.     Ihat  the  origm  or  these    extruded  from  the 

formations  is  parasitic  is  undoubtedly  true,  Tonsil(ExactSize). 
but  that  they  are  also  composed  of  broken-down  mucous  and 
epithelial  matter,  which  becomes  calcareous,  cannot  be  denied. 
One  such  tonsillar  specimen  is  delineated  in  Fig.  CXVIII. 
They  often  have  a  coralline  appearance  from  extension  into  the 
lacunal  ramifications. 

The  SYMPTOMS  to  which  these  formations  give  rise  are  prin- 
cipally those  of  a  foreign  body,  but  they  may  induce  or  keep  up 
considerable  inflammation,  and  they  also  occasion  great  foulness 
of  the  breath. 

Treatment  consists  in  their  removal,  and  the  setting  up  of 
adhesive  inflammation  in  the  holes  and  crypts  so  emptied.  Where 
the  tonsil  is  at  all  enlarged,  removal  of  a  piece  greatly  favours 
permanency  of  cure. 


CANCER  OF  THE  TONSIL  (Figs.  34  and  35,  Plate  IV.;  and 
Figs.  112  and  114,  Plate  XI II.). 

Malignant  disease  in  this  region  is  decidedly  rare.  I  have  seen 
only  twelve  cases  in  twenty  years,  or  about  i  in  5,000  cases  of 
throat  diseases. 

In  my  experience  the  growth  has  been  always  primary.  Some 
authorities,  however,  notably  ^'^Mandl,  say  that  cancer  of  the 
tonsil  may  be  secondary.  This  it  never  is  in  the  ordinary  accep- 
tation of  the  term,  though  the  tonsil  may  be  attacked  by  cancer 
either  of  the  sarcomatous  or  epithelial  variety,  by  invasion  of  the 
disease  from  the  tongue  or  other  part  in  its  immediate  vicinity. 
This  also  is  rare,  and  I  have  only  seen  three  cases  of  such  a 
nature.  One  was  that  of  a  patient  under  the  joint  care  of  Mr. 
Lloyd,  of  Bloomsbury,  and  of  Dr.  Llewelyn  Thomas.  The 
appearance  is  dehneated  in  Fig.  34,  Plate  IV.  The  case  is 
recorded  in  full  in  the  twenty-ninth  volume  of  the  Transactions  of 
the  Pathological  Society  of  London,  before  whom  the  patient  was 


262 


DISEASES  OF  THE  THROAT  AND  NOSE. 


exhibited  when  alive.  He  died  three  days  after  his  visit  to 
the  Society,  of  hsemorrhage,  the  second  in  the  course  of  the 
disease. 

Formerly  I  w^as  of  opinion  that  the  variety  of  cancer  as  it 
affects  the  tonsil  v^^as  that  of  scirrhus  or  encephaloid.  In  neither 
of  the  cases  considered  as  scirrhus  w^as  the  pathological  nature 
of  the  grov^th  distinguishable  by  its  stony  hardness  ;  thus,  as  it 
appeared  to  me,  illustrating  the  remark  of  Moore,  that  '  this 
character  is  far  from  being  universal  or  pathognomonic  '  of  this 
form  of  cancer.  In  two  of  the  cases,  however,  the  glands  in  the 
neighbourhood  were  characteristically  indurated.  There  is  at  the 
present  time  (December,  1886)  a  patient — a  housemaid,  aged  25 — 
under  my  care  in  hospital  with  such  a  condition ;  but  the  disease 
is  undoubtedly  a  lympho-sarcoma,  and  later  experience  and 
the  advancement  of  knowledge  as  to  the  varieties  of  cancer 
have  taught  me  that  these  cases  of  so-called  soft  scirrhus, 
if  the  anomaly  of  term  be  allowed,  are  lympho-sarcomata,  and 
that  this  is  the  most  usual  character  of  malignant  disease  of  the 
tonsil.  The  following  case  is  also  taken  from  the  same  volume 
(xxix.)  of  the  Pathological  Transactions,  and  I  depart  from  the 
usual  plan  of  this  work,  in  giving  it  and  one  or  two  others 
at  length,  because  of  the  comparative  rarity  of  the  disease,  and 
also  because  of  the  interesting  clinical  points  involved  in  the 
histories: 

Charles  F.,  set.  53,  a  carpet  beater  and  layer,  first  came  under  observation  at  the 
Central  London  Throat  and  Ear  Hospital  on  September  17,  1877,  complaining  of  throat 
trouble,  and  giving  the  following  history  : 

Had  long  been  subject  to  catarrhal  attacks  in  the  throat,  during  one  of  which  four 
years  previously  the  voice  had  been  temporarily  lost.  Had  never  suffered  from  any  injury 
to  the  throat,  nor  had  the  tonsils  ever  been  subjected  to  operation.  With  the  exception 
of  a  gouty  tendency,  his  family  history  was  good,  there  being  no  evidence  of  any  relative 
having  suffered  from  a  tumour,  simple  or  malignant. 

The  present  affection  was  considered  to  have  commenced  in  the  preceding  May,  when 
he  first  experienced  a  soreness  of  the  throat,  which  had  continuously  increased,  and  had 
been  followed  a  month  later  by  difficulty  in  swallowing.  These  symptoms  had  recently 
been  much  aggravated.  The  pain  was  constant ;  was  of  a  lancinating  character,  and 
extended  from  the  fauces  to  the  ears.  The  dysphagia  had  been  succeeded  by  difliculty  in 
nasal  respiration,  especially  through  the  right  nostril,  from  which  there  was  a  constant 
viscid  and  foetid  discharge. 

Eight  weeks  previously  the  glands  on  the  right  side  of  the  jaw  had  become  swollen  and 
painful.    He  was  conscious  of  having  lost  flesh  for  some  months. 

On  examining  the  interior  of  the  mouth  (Fig.  CXIX.,  and  also  Plate  IV.,  Fig.  35)  the 
mucous  membrane  of  the  whole  of  the  soft  and  hard  palate  on  the  right  side  was  seen  to 
be  uniformly  and  intensely  congested.  The  right  tonsil  was  considerably  enlarged,  but  no 
fluctuation  was  to  be  discovered  at  any  point.    The  soft  palate  and  uvula  were  pushed 


CANCER  OF  THE  TONSIL. 


263 


towardj  the  left  side.  Behind  the  right  posterior  faucial  arch  and  apparently  continuous 
with  the  enlarged  right  tonsil,  projected  an  irregular  fleshy  mass,  reaching  nearly  to  the 
middle  line,  extending  below  the  level  of  the  tongue,  and  obscuring  the  view  of  the 
pharynx  ;  it  was  of  a  deep  red  colour,  firm  in  consistence,  and  when  first  seen  was 
free  from  ulceration.  There  were  no  /ungating  masses,  and  there  was  no  tendency  to 
haemorrhage. 

Externally  there  was  a  well-defined 
lobulated  and  firm  swelling  behind  the 
ascending  ramus  of  the  lower  jaw,  ex- 
tending posteriorly  as  far  as  a  line  at  fall 

from  the  back  of  the  ear,  and  below  as 

far  as  the  level  of  the  jaw.    The  skin  was 

freely  movable  over  the  swelling,  and  was 

somewhat  congested.    The  whole  mass 

appeared  movable  on  the  subjacent  parts. 

The  sterno-cleido-mastoid.  muscle  was 

highly  projected  at  the  upper  attachment. 

There  was  no  pulsation,  inherent  or  trans-  ^^-^^r     -r  J   

^,    ,    .'  .  , ,  Fig.  CXIX.— Lympho-Sarcoma  OF  THE 

mitted.    The  glands  m  the  neighbour-      Tonsil  (see  also  Plate  IV.  Fig.  35). 
hood  of  the  parotid  were  not  enlarged, 

and  no  pain  was  caused  by  movement  of  the  jaw.  Weight  of  the  patient  at  first  visit  was 
12  stone. 

On  October  12,  a  month  after  his  first  application,  the  patient's  condition  was  reported 
as  having  steadily  deteriorated  ;  his  expression  was  worn,  and  his  countenance  was  very 
anaemic,  though  he  had  lost  no  blood  from  the  mouth,  nor  had  he  suffered  from  any  other 
haemorrhage.  He  experienced  great  pain  in  swallowing,  and  at  other  times,  so  that  he  was 
quite  unable  to  masticate ;  his  breathing  also  was  more  obstructed.  The  growth  had 
become  more  prominent  in  the  fauces ;  there  was  much  saliva  secreted,  and  there  was 
very  marked  and  characteristic  foetor  of  the  breath.  An  irritative  cough  gave  him 
much  trouble,  and  his  rest  was  greatly  disturbed  thereby.  His  weight  had  decreased 
4  lb. 

A  piece  of  the  growth  was  removed  by  means  of  the  galvano-cautery  loop  with  but  little 
pain,  and  with  very  trifling  haemorrhage.  The  piece  removed  weighed  about  3  drachms, 
was  of  a  greyish-yellow  colour,  mottled,  with  purplish  spots.  At  one  point  it  showed 
commencing  ulceration.  The  mass  was  slightly  lobulated,  and  was  freely  supplied  with 
bloodvessels.  The  central  part  was  of  dark  apple-jelly  colour,  semi-transparent,  and 
elastic  in  consistence.  Microscopic  examination  confirmed  the  diagnosis  as  to  the  malig- 
nancy of  the  growth,  which  was  thought  to  be  encephaloid  in  character. 

Twelve  days  later  (October  24)  the  patient  expressed  himself  as  much  relieved  ;  swallow- 
ing was  attended  with  less  pain,  and  breathing  was  easier.  His  weight  showed  a  decrease 
of  2^  lb.  since  the  last  date. 

On  November  i,  another  piece  of  the  growth  was  removed,  having  much  the  same 
character,  but  more  ulcerated.  The  operation  was  again  followed  by  considerable  relief. 
Deglutition  was  easier,  the  lancinating  pains  were  seldom  experienced,  but  the  patient 
complained  of  a  dull  heavy  pain  over  the  right  ear  and  side  of  the  head. 

He  visited  the  hospital  on  December  23,  vi^alking  both  to  and  from  his  house,  the 
distance  of  both  journeys  being  fully  two  miles.  His  weight  was  10  st.  2  lb.,  showing 
a  decrease  of  26  lb.  in  ninety-eight  days.    He  had  lost  7  lb.  in  the  last  fourteen  days. 

On  the  evening  of  the  24th  (that  is,  on  the  day  after  his  last  visit  to  the  hospital)  a 
sudden  attack  of  haemorrhage  took  place,  and  death  was  reported  as  having  ensued  in 
less  than  a  minute. 

Autopsy  moult  Sixty -three  Hours  after  Death  ^j/ Mr.  G.  R.  Steil. — The  larynx  and 
pharynx  with  the  tongue  and  the  cervical  swelling  were  removed  entire. 

The  cervical  tumour  was  marked  by  a  shallow  groove  running  downwards  and  out- 


264 


DISEASES  OF  THE  THROAT  AND  NOSE. 


wards,  and  dividing  it  into  a  posterior  upper  and  an  anterior  lower  and  larger  part. 
Above  the  mass,  lying  in  front  of  the  internal  jugular  vein  and  against  the  pharyngeal 
wall,  was  seen  the  spinal  accessory  nerve,  which,  passing  beneath  the  upper  part  of  the 
tumour,  emerged  at  the  groove.  The  posterior  division  of  the  mass  was  firmly  attached 
at  the  upper  part  of  the  base  of  the  skull  and  the  transverse  processes  of  the  upper  two 
vertebrae  ;  in  front  of  it  was  the  styloid  process  of  the  temporal  bone.  The  anterior  and 
larger  division,  ovoid  in  shape,  was  partly  covered  by  the  sterno-cleido-mastoid  muscle. 
Above  it  lay  the  posterior  belly  of  the  digastric  and  the  stylo-hyoid  muscles  ;  below  it  was 
free,  whilst  in  front  it  merged  into  the  thickened  and  infiltrated  pharynx.  The  tumour 
was  of  a  smooth,  slightly  lobulated  surface,  of  a  pinkish-yellow  colour,  and  semi-elastic 
to  sense  of  touch,  giving  the  idea  that  it  contained  fluid.  On  section  it  was  at  first  firm, 
but  the  centre  part  was  softer.  It  was  of  a  yellowish-grey  colour  mottled  with  pink.  Oa 
pressure  there  was  characteristic  juicy  exudation.  There  were  a  few  smaller,  enlarged, 
and  indurated  glands  in  the  neighbourhood. 

The  common  carotid  artery,  with  the  internal  jugular  vein  and  accompanying  nerves, 
were  pressed  back  and  lay  beneath  the  tumour ;  the  external  carotid  was  seen  to  emerge 
from  behind  it  at  its  upper  border.  Anteriorly  it  was  pierced  by  the  superior  laryngeal 
and  the  lingual  arteries. 

The  whole  of  the  soft  palate  and  the  upper  walls  of  the  pharynx  were  thickened  and 
infiltrated.  The  tonsillar  mass,  which  originally  projected  from  behind  the  posterior 
arch  of  the  palate,  had  become  greatly  reduced  by  sloughing,  which  had  also  attacked 
the  right  pharyngeal  wall.  Several  vessels  were  seen  to  be  dissected  by  the  ulceration  in 
the  wall  of  the  pharynx,  but  even  on  most  careful  examination  no  arterial  branch,  tonsillar 
or  pharyngeal,  was  traceable  from  the  facial  to  the  ulcerating  and  sloughing  parts  ;  so 
that  it  was  impossible  to  say  exactly  whence  the  haemorihage  had  proceeded.  The  larynx 
was  healihy,  and  the  tongue  also  was  uninvaded.  No  other  organs  were  permitted  to  be 
examined. 

Report  of  the  Committee  ott  Morbid  Growths. — The  parts  forwarded  to  us  consisted  of  a 
piece  hardened  in  chromic  acid,  some  pieces  of  diseased  gland  in  glycerine,  and  the 
tongue,  larynx,  and  adjacent  parts  in  spirit. 

The  latter  parts  are  the  seat  of  a  large  soft  growth  which,  springing  from  the  right  side 
in  the  neighbourhood  of  the  tonsil,  infiltrates  and  thickens  the  posterior  wall  of  the 
pharynx  and  the  soft  palate.  The  posterior  walls  of  the  pharynx  and  the  tonsillar  region 
show  a  ragged  sloughy  surface. 

Under  the  microscope  all  these  parts  have  a  very  similar  structure.  The  stroma  forms 
a  delicate  reticulum,  enclosing  small  cells  with  single  nucleus,  and  occasionally  much 
larger  cells  also  with  single  nucleus.  In  the  tonsillar  region  the  cells,  though  small,  are 
decidedly  angular  ;  in  the  glandular  mass  outside  it  they  are  mostly  circular.  This 
difference  in  the  shape  of  the  cells  appears  to  be  a  local  accident,  due  rather  to  mutual 
compression  than  to  any  essentially  different  type  of  growth  in  the  tw^o  parts,  and  we 
consider  the  disease  to  be  a  lympho-sarcoma.  The  nature  of  the  growth,  and  the  absence 
of  any  tonsil  structure,  make  it  probable  that  the  latter  may  have  been  the  original  seat 
of  the  disease. 

March,  1878. 

Primary  epithelioma  of  the  tonsil  is,  although  rare,  not 
unknown,  and  three  cases  have  occurred  in  my  own  practice. 

The  first  was  exhibited  as  a  living  specimen  at  the  Pathological  Society,  December  3, 
1879,  and  is  recorded  in  vol.  xxx.  of  the  Transactions.  The  paiient  was  an  engine- 
rlriver  of  temperate  habits,  who,  until  within  the  last  year,  had  enjoyed  good  health,  with 
the  exception  of  temporary  sore  throat  on  the  same  side  as  now  affected  seven  years 
previously.    He  had  been  treated  at  various  hospitals,  chiefly,  as  it  appeared,  for  syphilis, 


CANCER  OF  THE  TONSIL. 


265 


and  he  applied  at  the  Central  Throat  and  Ear  Hospital  on  November  21st.  The  follow- 
ing were  the  principal  points  in  bis  condition  :  He  was  pale  and  evidently  emaciated, 
weighing  iio|lb.  as  against  126  lb.  six  months  previously.  His  general  health  nnd 
appetite  were  poor  ;  his  pulse  92.  Both  voice  and  articulation  were  slightly  nasal ;  his 
left  nostril  was  obstructed,  but  there  was  no  impediment  in  oral  breathing,  nor  in  the 
mobility  of  the  tongue.  His  breath  was  very  foetid.  He  stated  that  swallowing  of  solids 
had  become  impossible,  and  that  he  lived  principally  on  bread  and  milk  and  soup.  His 
sense  of  taste  had  become  hnpaired. 
He  complained  of  a  shooting  pain 
starting  below  the  ear  as  soon  as  he 
got  warm  in  bed,  with  considerable 
pain  in  taking  food  if  he  attempted  to 
swallow  it  at  all  hot.  His  family  his- 
tory was  good.  He  denied  having  had 
syphilis. 

On  examining  the  mouth  it  was 
seen  that  the  left  half  of  the  soft  palate 
and  corresponding  tonsil  and  faucial 
pillar  were  occupied  by  an  almost 
white,  but,  in  parts,  slightly  pink, 
fungatory  growth  extending  from  the 
left  side  of  the  tongue  and  for  a  con- 
siderable distance  down  into  the 
pharynx.  The  uvula,  as  will  be  seen 
by  reference  to  the  drawing  (Fig. 
CXX.),  and  to  the  coloured  illustration 
(Fig.  114,  Plate  XHL),  was  much 
pushed  to  the  right  of  the  mesial  line, 
being  on  a  perpendicular  level  with  the 
second  right  bicuspid.  The  new  growth 
was  closely  connected  with  the  lower  jaw,  and  the  tissue  of  the  soft  palate  around  it 
was  red  and  swollen,  but  not  indurated.  Beneath  the  left  angle  of  the  lower  jaw 
was  felt  a  hard  fixed  lump  (glandular)  extending  to  the  top  of  the  hyoid  bone. 

A  portion  of  the  growth  was  removed  by  means  of  the  galvano-cautery  loop  and 
submitted  to  microscopic  examination,  which  showed  it  to  be  composed  of  abundant 
proliferation  of  epithelial  cells  with  but  scanty-celled  stroma.  The  patient  remained 
under  treatment  for  ten  months  :  large  pieces  of  the  growth  were  removed  by  the  galvano- 
caustic  loop  or  by  ordinary  wire  ecraseur  almost  each  week,  at  the  express  desire  of  the 
patient,  who  experienced  great  relief  thereby  in  both  his  breathing  and  swallowing. 
Nevertheless  the  disease  progressed,  and  finally  involved  the  base  of  the  tongue, 
epiglottis,  and  angle  of  the  jaw.  He  kept  at  work  till  three  months  before  his  death, 
which  took  place  fifteen  months  after  his  first  visit  to  the  hospital.  He  died  at  his  own 
home,  and  an  autopsy  was  not  obtainable. 


Fig.  CXX.— Primary  Ei-ithelioma  of  the 

TuNSIL. 


I  have  also  been  recently  in  attendance,  in  conjunction  with 
Dr.  White,  of  Retford,  on  a  gentleman,  aged  60,  the  subject  of  an 
indurated  warty  hypertrophy,  with  ulceration  of  the  right  tonsil 
and  uvula,  which  has  all  the  characters^  macroscopic  and  micro- 
scopic, of  epithelioma. 

Another  instance  of  epithehoma  not  exactly  in  the  tonsil,  but  in 
its  immediate  neighbourhood,  is  delineated  in  the  accompanying 
figure  (CXXL),  and  also  in  colour  as  Fig.  112,  Plate  XIII. 


266 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Fig. 


CXXI. — Epithfxioma  of  Anterior 
Pillar  of  Faucks. 


The  drawing  was  made  from  a  patient  whom  I  only  saw  once  in  February,  1879.  He 
was  a  man  of  52  years  of  age,  who  had  always  enjoyed  good  health  until  within  the 
liist  three  or  four  months,  since  which  time  he  had  experienced  pain  in  swallowing.  He 

had  not  become  thinner.  Both  nares 
and  larynx  were  slightly  congested. 
The  patient  stated  that  he  had  always 
been  a  great  snuff-taker. 

On  examining  the  mouth  the  whole 
of  the  soft  palate  was  seen  to  be  unduly 
hypersemic,  capillaries  coursing  over  its 
surface  as  shown  in  the  illustration. 
There  was  a  small  warty  growth  about 
the  region  of  the  anterior  pillar,  and 
was  of  such  a  character  that  I  had  no 
difficulty  in  diagnosing  it  as  an  epi- 
thelioma. The  patient  allowed  me  to 
remove  a  fragment  for  microscopic 
c\-nmination,  which  entirel3'  confirmed 
my  belief  in  the  malignancy  of  the  disease  ;  but  I  could  not  induce  him  to  have  the  little 
growth  removed,  nor  have  I  been  able  to  ascertain  any  details  of  the  further  progress  of 
the  case.  It  should  be  mentioned  that  there  were  no  enlarged  glands,  but  there  was 
distinct  tenderness  on  external  pressure  under  the  angle  of  the  left  jaw. 

In  the  case  of  Charles  F.,  the  cervical  glands,  though  much 
enlarged,  were  by  no  means  hardened.  Microscopic  examination 
of  portions  of  the  tumour  which  were  removed  on  two  separate 
occasions  during  life,  gave  undoubted  evidence  of  its  malignant 
nature,  and  this  opinion  was  confirmed  after  death. 

In  some  instances  there  is,  especially  in  the  early  stages,  but 
little  apparent  enlargement  of  the  tonsil  itself,  since  infiltration 
of  the  surrounding  tissues  obscures  any  definition  of  the  tumour. 
So  much  is  this  the  case,  that  a  correct  diagnosis  is  generally 
arrived  at  rather  from  a  careful  consideration  of  the  general  and 
commemorative  signs  than  of  the  subjective  symptoms,  or  from 
the  physical  examination  of  the  gland  itself. 

Thus  all  functional  symptoms,  as  well  as  all  physical  signs, 
will  bear  a  strong  analogy  to  those  of  any  inflammatory  tonsillar 
affection.  Voice  will  be  thick,  articulation  impeded,  respiration 
obstructed,  deglutition  painful,  and  the  special  senses  of  smell 
and  taste  impaired.  Physically  there  will  be  redness,  thickening 
with  displacement,  possibly  ulceration  and  disorder  of  secretion. 
Examining  more  closely,  we  shall  find  that  the  pain  of  malignant 
disease  is  much  more  severe  than  in  any  benign  inflammation  of 
a  chronic  character.  It  is,  in  point  of  fact,  very  like  the  pain  of 
quinsy,  only  lasting  for  months,  instead  of  for  four  or  five  days, 
and  is  only  second  in  intensity  to  that  which  sometimes  accom- 
panies tuberculous  ulceration  in  the  same  region.  Pain  in  the 
ears,  so  characteristic  also  of  similar  disease  in  the  larynx,  is  a 


CANCER  OF  THE  TONSIL, 


267 


distinctive  symptom,  and  deafness  and  tinnitus  are  often  present. 
The  colour  of  a  sarcoma  is  generally  of  a  dusky,  livid  red,  with 
infiltration  extending  far  beyond  the  ordinary  bounds  of  inflam- 
mation, and  with  patches  of  ulceration  or  granulations  ;  the  tumour 
of  an  epithelioma  is  of  paler  tint,  and  is  fairly  well  rendered  in  the 
coloured  illustrations,  especially  those  on  Plate  XIIL;  the  secre- 
tion will  be  thin  and  sanious,  not  thick  and  chees}^  as  in  lacunar 
inflammations  of  benign  character,  and  it  will  be  very  offensive. 
It  will  require  to  be  constantly  cleared  from  the  mouth,  and  will 
also  be  discharged  freely  from  the  nostrils. 

The  general  health  speedily  suffers,  nutrition  is  impaired,  and 
the  patient  steadily  loses  weight.  This  loss  of  weight  is  regarded 
in  my  practice  as  a  distinctive  feature  of  the  first  importance. 
In  the  case  alluded  to,  as  brought  to  me  by  Dr.  White,  an 
opinion  had  been  repeatedly  expressed  by  another  specialist  that  the 
case  was  one  of  syphilis.  The  patient  had  lost  a  stone  in  weight 
in  the  three  months  previous  to  seeing  me,  the  effect,  as  he  was 
assured,  of  iodide  of  potassium  :  when  I  saw  him  he  weighed 
over  16  stone,  and  the  patient  had  been  rather  congratulated 
on  his  loss.  In  twenty  days  which  elapsed  before  his  next  visit 
he  lost  6J  lb.,  and  this  sign  enabled  us  to  definitely  confirm  the 
doubts  we  had  felt  as  to  the  correctness  of  the  diagnosis  of  the 
malady  as  syphilitic. 

Diagnosis. — It  is  often  said  that  the  error  of  mistaking  cancer 
of  the  tonsil  for  syphiUs  is  a  very  pardonable  one,  as  the  marks  of 
difference  between  the  two  diseases  are  by  no  means  distinct. 
Indeed,  this  was  once  said  by  the  President  for  the  time  being  of 
the  Pathological  Society,  on  the  occasion  of  my  exhibiting  a  case 
of  cancer.  I  ventured  to  dissent  from  that  view,  and  stated  that 
though  the  patient's  own  account  may  not  by  any  means  exclude 
the  possibility  of  a  co-existent  syphilitic  dyscrasia,  the  method  in 
which  the  two  diseases  affect  the  tonsil  (or,  indeed,  any  other  part 
of  the  throat)  is  wholly  distinct.  To  more  particularly  emphasize 
these  differences  I  have  contrasted  the  chief  features  of  the  two 
diseases  in  opposing  columns  : 


Syphilis. 

Ftoictional  Symptoms.  —  Swallowing 
sometimes  difficult,  but  never  impossible, 
though  occasionally  leading  to  return  of 
fluids  through  the  nostrils  ;  the  sensation  is 
essentially  one  of  discomfort  rather  than 
pain,  with  entire  absence  of  pain  when  the 
parts  are  at  rest. 


Cancer. 

Functional  Symptoms. — Dysphagia,  as 
it  is  the  first,  is  also  the  prominent  symptom, 
and  increases  in  severity  so  as  to  lead  to 
total  inability  to  take  food.  Acute  lan- 
cinating pain  is  a  prominent  and  almost 
constant  symptom. 


268 


DISEASES  OF  THE  THROAT  AND  NOSE. 


S>Y\muAS—{cojttimied). 
Physical  Signs. — The  tonsils  are  generally 
afifected  by  syphilis  in  its  earlier  (secondary) 
stages  by  deposits  on  their  surface  of  mucous 
patches  ;  in  the  advanced  stages  (tertiary) 
syphilis  attacks  the  gland  as  a  perforating 
ulcer.  There  is  but  slight  sympathetic 
glandular  enlargement,  which  is  not  painful 
and  subsides  with  the  cause  of  irritation. 

Haemorrhages  are  rare. 

Emaciation,  if  existing,  is  only  in  pro- 
portion to  diminished  nutriment  taken. 

Therapeutic. — Most  amenable  to  appro- 
priate treatment. 


C  A  N  c  E  R — [contiii  J  led). 
Physical  Signs. — Cancer,  whatever  the 
form,  is  always  manifested  in  the  tonsils  as 
a  new  growth,  which  attains  considerable 
size  before  the  occurrence  of  ulceration. 
There  is  considerable  infiltration  and  in- 
duration of  neighbouring  glands,  which 
become  as  painful  as  the  primary  seat  ot 
disease. 

Hoemorrhages  are  frequent  and  profuse, 
and  are  often  the  immediate  cause  of  death. 

Rapid  emaciation  commences  long  before 
dysphagia  is  by  any  means  extreme,  and 
advances  even  with  relief  of  symptoms. 

Therapetitic. — Advances  in  spite  of  every 
measure,  medicinal  or  surgical. 


There  is  but  little  likelihood  of  cancer  in  the  tonsil  being  mis- 
taken for  any  other  disease.  Its  points  of  differentiation  from 
benign  inflammations  were  detailed  at  page  248. 

Prognosis,  it  need  scarcely  be  said,  is  most  unfavourable, 
although  the  progress  of  the  disease  may  be  very  slow,  and  the 
patient  experience  temporary  relief  on  occurrence  of  ulceration 
or  haemorrhages.  With  advance  of  the  malady  the  sufferer 
becomes  painfully  depressed,  and  at  an  early  stage  presents  the 
well-known  signs  of  the  cancerous  cachexia. 

Death  occasionally  occurs  suddenly,  and  is  in  that  case  generally 
due  to  haemorrhage  or  to  sudden  secondary  oedema  of  the  larynx. 
An  instance  of  this  latter  kind  occurred  in  1877  at  the  Central 
Throat  and  Ear  Hospital. 

The  patient,  a  man  cet.  44,  was  admitted  on  account  of  a  malignant  ulceration  at  the 
base  of  the  tongue,  not  involving  either  larynx  or  tonsil ;  •  but  there  was  an  enormous 
indurated  mass  at  the  side  of  the  neck,  extending  from  the  angle  of  the  jaw  right  down  the 
length  of  the  trachea.  The  man  died  suddenly  with  barely  a  spasm,  and  on  post-mortem 
examination  oedema  of  the  epiglottis  and  left  ary-epiglottic  fold  was  found.  The  larynx 
was  otherwise  healthy,  except  that  the  left  recurrent  nerve  was  inextricably  involved  in 
the  mass,  and  there  was  wasting  of  the  left  posterior  crico-arytenoid  muscle. 

Other  modes  of  death  are  by  gradually  progressive  systemic 
cachexia  and  by  inanition. 

Treatment. — Temporary,  and  even  considerable,  relief  may 
be  given  by  the  removal  of  portions  of  the  tumour  by  means  of 
the  ecraseur  or  galvano-cautery ;  but  there  are  no  means  of 
eradicating  the  disease,  or  even  of  otherwise  arresting  its  slow  and 
certain  march  to  a  fatal  issue.  Recorded  experience  of  the  opera- 
tion of  resection  of  a  portion  of  the  jaw  in  the  hands  of  others 
has  not  yet  induced  me  to  recommend,  much  less  to  perform, 


CANCER  OF  THE  TONSIL. 


26^ 


it.  As  palliatives,  the  local  internal  application  of  chloride 
of  zinc,  iodine,  iodoform,  or  iodol  (Form.  56,  64,  65),  may 
be  recommended,  with  external  applications  of  chloral  (Form.  58) 
or  of  belladonna.  The  painting  of  a  five  or  ten  per  cent,  solution 
of  cocaine  internally,  and  injections  of  the  same  or  of  morphia 
hypodermically,  are  also  recommended.  The  benefit  of  this 
remedy  is,  however,  somewhat  discounted  by  its  tendency  to 
increase  salivation ;  and  in  such  circumstances  a  spray,  wash,  or 
lozenge  of  menthol  may  be  usefully  substituted.  Sedatives  applied 
to  the  external  auditory  meatus  will  in  some  instances  relieve  the 
distressing  ear-ache. 

REFERENCES  TO  AUTHORITIES. 


NO. 


240 

I 

243 

2 

243 

3 

243 
244 

4 
5 

244 

6 

249 

7 

253 

8 

255 
258 

9 
10 

259 

II 

261 

12 

261 

13 

262 

14 

NAME. 


Kingston  Fox. 

F.  T.  Roberts. 

John  J.  Reid. 

W.  McN.  Whistler. 
C.  Haig  Brown. 

Kingston  Fox. 

SoLis  Cohen. 

Wesley  Mills. 

Andrew  Smith. 

G.  M.  Lefferts. 

Wagner. 

Emil  Gruening. 
Mandl. 

Moore. 


title  of  work  referred  to. 


{Functions  cf  the    Tonsils  :   fotirnal  of 
Anatomy  and  Physiology^  part  iv.,  p. 
559.    London,  1886. 
^Handbook  of  Theory  and  Practice  of  Medi- 
y    cine,  3rd  edition,  vol.  i.,  p.  228. 
i  Archives  of  Laryngology,  vol.  i.,  p.  229. 
\    New  York,  1881. 
The  Specialist,  January,  1881. 
Tonsillitis  in  Adolescents.    London,  1886. 
/  Transactions  of  the  Medical  Society  of 
\    London,  vol.  ix.,  p.  255  et  seq. 
Op.  cif.,  p.  89. 

(Archives  of  Laryngology,  vol.  iii.,  p.  62. 
\    New  York,  1882. 
Lbid.,  p.  146. 
Lbid.,  p.  38. 

i  Von  Ztenissen^s  Cyclopedia  of  Medicine,. 
\  English  Translation,  vol.  vi.  London, 
I  1876-77. 

(Archives  of  Laryngology,  vol.  iii.,  p.  136. 
\    New  York,  1882. 

(Maladies  du  Larynx  et  dii  Pharynx. 
\    Paris,  1872. 

{Holmes's  System  of  Surgery,  2nd  edition, 
p.  554.    London,  1870. 


CHAPTER  XII. 


DISEASES  OF  THE  LARYNX:  ANJEMIA,  HYPERJEMI A— CLASSI- 
FICATION OF  LARYNGEAL  INFLAMMATIONS. 

The  larynx  is  subject  to  all  the  affections  peculiar  to  a  mucous 
tract,  with  certain  additional  disorders  due  to  its  structural 
arrangement  and  its  functional  purposes :  thus  we  have  anaemia, 
hypersemia,  congestions,  inflammations,  ulcerations,  and  cica- 
tricial deformities,  with  thickenings  due  to  submucous  deposit. 
All  these  are  either  of  a  simple  character,  or  associated  with  some 
specific  poison,  and  both  are  acute  and  chronic. 

Any  interference  with  innervation  of  the  muscles  which  either 
open  or  close  the  rima  glottidis  will  lead  to  disorder  of  both 
respiration  and  vocalization  ;  or  the  chink  may  be  narrowed  by 
inflammatory  thickening,  membranous  exudation,  cicatricial  adhe- 
sion, or  nevv^  formations.  The  framework  of  the  larynx  being 
composed  of  cartilages  and  their  articulations,  morbid  processes 
may  extend  to  these  tissues,  leading  to  ossification,  anchylosis, 
caries,  and  disintegration. 

Lastly,  external  disease  may  by  compression  diminish  the 
calibre  of  the  larynx,  or  it  may  invade  the  canal  itself;  in  either 
case  interfering  with  the  free  passage  of  air,  and  possibly  leading 
to  the  introduction  of  noxious  foreign  matter. 

A  few  notes  on  the  general  structure  of  the  larynx  will  be  of 
service  towards  appreciation  of  changes  made  by  disease. 

Commencing  with  a  more  minute  description  of  the  histology 
of  the  mucous  membrane  than  was  given  in  the  prehminary 
remarks  on  its  anatomy  (p.  20)  we  find  that — 

I.  — The  greater  portion  of  the  larynx  has  a  lining  of  stratified  columnar  ciliated  epi- 
thelium. Interspersed  are  a  few  goblet  cells,  and  here  and  there  the  openings  of  the 
niucous  glands. 

II.  — A  basement  membrane. 

III.  — The  mucosa,  which  consists  of  a  meshwork  of  fibrous  ccnnective-tissue,  with  more 


ANEMIA  OF  THE  LARYNX. 


27, 


or  less  adenoid  tissue,  the  latter  being  sometimes  aggregated  to  form  lymph  follicles : 
these  are,  however,  not  nearly  so  numerous  as  in  the  tonsils  and  pharynx.  In  this 
mucosa  are  contained  the  lymphatics  and  the  smaller  branches  of  vessels  and  nerves. 

IV. — The  submucosa,  composed  of  tissue  of  the  areolar  variety,  with  a  certain  amount 
of  adenoid  stroma:  in  it  is  situated  fat-cells,  mucous  glands,  and  the  larger  vessels  and 
nerves. 


Fig.  CXXIL— Section  of  Vocal  Cord  and  Ventricle,  Magnified  about 
45  Diameters  (after  ^Klein). 

c.  Vocal  cord,  with  covering  of  stratified     i/.  Ventricle   with  stratified  columnar 

pavement  epithelium.  ciliated  epithelium. 

^.  Elastic  fibrillge  of  the  same.  e.  Adenoid  tissue  (laryngeal  tonsil). 

c.  Section  of  thyro-arytenoid  muscle.  /.  Ventricular  band,  with  epithelium  of 

both  varieties. 

Variations  of  the  structure  will  be  found  in  the  following  regions : 

On  the  epiglottis,  the  vocal  cords  and  the  superior  surface  of  the  ventricular  bands,  the 
epithelium  is  of  the  stratified  pavement  variety. 

The  mucous  glands  and  adenoid  tissue  are  most  prevalent  on  the  ventricular  bands  ; 
that  is  to  say,  on  the  most  lax  portion  of  the  lining.  They  are  entirely  absent  on.  the 
vocal  cords, which  are  composed  solely  of  a  layer  of  stratified  pavement  epithelium,  a 
distinct  and  firmly  adherent  basement  membrane,  and  elastic  fibrillx. 

ANEMIA  OF  THE  LARYNX  (Fig.  68,  Plate  VIII.). 

When  a  patient  is  suffering  from  general  ansemia,  whether  due 
to  haemorrhagic  loss  or  chlorosis,  from  Bright's  disease  or  diabetes, 
the  capillary  supply  to  the  larynx  may  of  course  be  diminished,  in 
common  with  that  to  the  rest  of  the  body ;  and  this  affection, 
therefore,  does  not  require  particular  notice.  The  cases  in  which 
laryngeal  ansemia  is  of  significant  importance  are  :  i.  Whe   it  is 


272 


DISEASES  OF  THE  THROAT  AND  NOSE. 


associated  with  functional  aphonia ;  2.  When,  during  the  course 
of  an  attack  of  chronic  laryngitis,  the  mucous  membrane  covering 
the  ary-epiglottic  folds,  arytenoid  cartilages,  and  ventricular  bands 
is  abnormally  pale,  while  the  vocal  cords  are  the  seat  of  indolent 
congestion,  the  patient  not  being  generally  anaemic.  In  both 
these  cases  the  condition  may  be  the  premonitor  of  laryngeal 
tuberculosis ;  it  will,  therefore,  when  so  occurring,  be  more 
properly  considered  in  the  chapter  on  that  disease. 

The  laryngeal  mucous  membrane  may  partake  of  the  charac- 
teristic change  of  the  cutaneous  surface  observed  in  cyanosis  and 
in  jaundice. 

Treatment  must  naturally  depend  on  the  primary  cause,  and 
all  local  measures,  as  stimulating  inhalations,  lozenges,  etc., 
should  be  secondary  to  general  tonic  remedies. 

HYPEREMIA  AND  HEMORRHAGES  OF  THE  LARYNX. 

This  condition  seldom  occurs  except  as  the  precursor  or  sequel 
of  inflammation,  congestion  of  the  laryngeal  mucous  membrane 
being  usually  due  to  catarrhal  influences.  Active  hyperaemia  is 
also  observed  in  the  larynx  of  persons  in  habitual  use  of  the 
voice  ;  of  those  addicted,  to  chronic  alcoholism,  or  to  the  excessive 
use  of  tobacco;  of  those  working  continuously  amid  acrid 
chemical  fumes,  as  of  phosphorus  and  the  corrosive  acids  or 
alkalies,  smoke,  dust,  or  in  ill-ventilated  rooms  overcharged  with 
carbonic  acid  gas.  In  these  the  congestion,  though  not  always 
reaching  the  stage  of  disease,  renders  the  subject  thereof  most 
prone  to  contract  more  acute  inflammation. 

As  first  pointed  out  by  myself  many  years  ago,  the  larynx  of 
most  voice-users  is  in  a  state  of  active  hyperaemia  of  varying 
intensity,  without  the  existence  of  any  pathological  symptoms. 
This  circumstance,  however,  will  explain  one  of  the  predisposing 
causes  of  this  class  to  laryngeal  inflammations. 

Pathology. — The  various  regions  of  the  larynx  difl'er  widely  in 
the  amount  of  hyperaemia  they  exhibit,  and  such  differences 
depend  in  most  part  upon  the  relative  thickness  and  tension  of 
the  mucous  covering  and  the  structures  lying  immediately  beneath. 
Hyperaemia  is  always  more  diffuse  and  pronounced  where  the 
submucosa  is  loose,  fat,  and  thick,  as  upon  the  ary-epiglottic  folds, 
the  false  cords,  ventricular  bands,  and  the  ventricles ;  whereas 
over  the  epiglottis,  true  cords,  and  inferior  cavum  of  the  larynx, 
only  comparatively  slight  differences  in  colour  are  to  be  observed 
even  in  congestions  of  rather  high  grade.  Besides  being  present 
in  all  acute  processes,  hyperaemia  of  the  mucous  membrane  of 


HYPER^EMIA  AND  H/BMORRHAGES  OF  THE  LARYNX.  273 


the  throat  is  an  almost  invariable  accompaniment  of  the  exan- 
themata. Slight  ecchymoses  frequently  happen  during  active 
hypersemia,  but  otherwise  haemorrhage  is  of  rare  occurrence 
except  from  mechanical  injury.  A  case  has  been  reported  by 
^Tiirck,  in  which  haemorrhage  resulted  from  syphilitic  ulceration 
in  the  sinus  pyriformis,  leading  to  corrosion  of  the  lingual  artery. 
This  is  the  only  instance  recorded  of  such  an  accident,  though 
many  authors  mention  the  possible  danger  of  its  occurrence. 
Haemorrhages  are  not  infrequent  in  carcinoma,  and  are  occa- 
sionally witnessed  in  phthisis.  A  case  in  connection  with  the  last- 
named  disease  is  illustrated  in  Plate  VIII.,  Fig.  69. 

Another  interesting  instance  of  this  rare  condition  is  illustrated 
in  Plate  XIX.,  Fig.  118.  It  was  probably  an  example  of  what 
^Navratil  has  termed  Chovditis  hcumorrhagica. 

The  subject  was  a  young  girl,  Charlotte  Y.,  aged  18,  by  occupation  a  seamstress,  who 
was  seen  by  me  at  the  hospital,  in  February,  1879,  conjunction  with  my  former  col- 
league, Mr.  Hamilton.  She  applied  on  account  of  complete  loss  of  voice,  and  the  appear- 
ance presented  in  the  picture  was  seen  on  laryngoscopic  examination,  viz.,  general  anaemia, 
with  the  exception  of  the  vocal  cords,  which  were  coloured  with  moist  blood.  On  wiping 
the  hoemorrhagic  covering  away,  the  cords  were  seen  to  be  markedly  hypersemic.  There 
was  but  little  history  obtainable,  except  that  of  poor  feeding  and  general  debility  with 
amenorrhoea.  The  patient  stated  that  she  had  often  tasted  blood,  and  had  spat  a  little  into 
her  handkerchief  at  early  morning,  but  had  never  had  further  evidence  of  hccmoptysis. 
The  lungs  were  weak,  but  not  actively  diseased. 

The  girl  improved  under  internal  administration  of  iron  and  ergot,  and  her  voice  was 
restored  as  her  strength  was  regained  ;  but  except  on  her  return  from  a  Convalescent  Home, 
she  was  not  again  seen. 

Venous  congestion  is  by  no  means  so  infrequent  as  is  gener- 
ally stated.  I  have  seen  engorgement  of  the  venous  plexus  which 
is  encased  in  the  mucous  folds  that  bind  the  tongue  to  the 
epiglottis,  in  cases  of  mitral  insufficiency,  as  remarked  by  Dickson. 
Passive  hyperaemia  is  likewise  seen  in  emphysema,  and  it  may 
also  be  caused  through  the  pressure  of  external  tumours,  by  severe 
cough,  and  by  anything  leading  to  straining  or  forcing  of  the  vocal 
or  respiratory  functions.  It  has  been  already  noted,  at  page  208, 
that  a  hasmorrhoidal  condition  of  the  veins  at  the  base  of  the 
tongue  is  a  cause  not  generally  recognised  of  many  throat  troubles 
hitherto  considered  as  of  a  purely  subjective  nature.  It  is  perhaps 
needless  to  mention  that  in  icterus,  as  well  as  in  gangrenous  pro- 
cesses in  the  lungs,  the  lining  membrane  of  the  pharynx  and 
larynx  takes  on  that  discoloration  in  which  all  other  mucous 
surfaces  then  participate. 

Symptoms  :  Functional.  —  The  voice  Is  generally  some- 
what hoarse ;  respiration  is  unembarrassed,  unless  there  is 
nasal  or  pharyngeal  stenosis;  cough  exists  rather  as  result 
of  a  desire  to  clear  the  throat  of  supposed  irritation  than 


274 


DISEASES  OF  THE  THROAT  AND  NOSE. 


from  more  direct  cause  ;  and  pain  with  sensation  of  dryness  or  of 
a  foreign  body  is  experienced. 

Objective  symptoms  are  at  once  revealed  by  the  laryngo- 
scope, and  consist  of  increased  coloration  of  the  mucous 
membrane  in  varying  degrees  of  uniformity  and  intensity.  The 
degree  and  situation  of  varix  are  always  to  be  verified  by  direct 
inspection  or  by  the  laryngeal  mirror. 

In  the  case  of  haemorrhage  the  source  of  bleeding  may  some- 
times be  accurately  ascertained,  as  is  seen  in  the  illustrations  in 
Plates  VIII.  and  XIV. 

Progress  and  Duration.— Neglect  of  a  congestion  of  the 
larynx  is  likely  to  lead  to  subacute  or  chronic  laryngitis,  and 
may  be  a  predisponent  to  even  more  severe  grades  of  inflam- 
mation. A  haemorrhage  from  the  larynx  is  almost  invariably  in- 
dicative of  serious  disease. 

Treatment  should  in  the  case  of  secondary  hyperaemia  be 
modified  according  to  the  cause,  with  adoption  of  measures,  local 
and  general,  of  much  the  same  nature  as  recommended  for  chronic 
laryngitis  (p.  278).  In  haemorrhages,  insufflations  of  alum  or  in- 
troduction by  the  laryngeal  syringe  or  brush  of  solutions  of  persul- 
phate of  iron,  half  to  one  per  cent.,  are  preferable  to  similar 
applications  of  tannin.  '^Stockman's  recent  experiments  have 
shown  that  the  action  for  good  of  this  last-named  drug  depends 
on  its  power  of  precipitating  albumen,  the  layer  of  tannate  of  albu- 
men which  is  formed  acting  as  a  protective  to  the  underlying 
mucous  membrane;  but  it  has  also  been  shown  by  ^Rosenstirn 
and  ^Fikentscher  that  tannic  acid  when  locally  applied,  so  far 
from  causing  contraction  of  bloodvessels  is  actually  followed  by 
their  dilatation.  Internal  administration  of  tannic  and  galUc  acid 
has  also  been  proved  to  be  of  no  effect  on  the  respiratory  mucous 
membrane.  In  cases,  therefore,  of  laryngeal  haemorrhage  iron 
and  ergot  are  preferably  indicated. 

INFLAMMATIONS  OF  THE  LARYNX. 

Much  confusion  has  been  occasioned  in  the  classification  of 
inflammatory  diseases  of  the  larynx,  by  the  want  of  agreement  on 
the  part  of  various  authors  as  to  the  significance  of  terms.  It  is 
here  proposed  to  arrange  laryngeal  inflammations  in  separate 
order,  principally  in  relation  to  the  nature  of  the  structure  involved, 
each  in  its  acute  and  subacute  or  chronic  form,  and  to  the  indi- 
vidual character  of  the  morbid  process. 

The  laryngeal  complications  occurring  during  the  course  of 
certain  continued  fevers  and  of  the  exanthemata  vary  in  nature 


INFLAMMATIONS  OF  THE  LARYNX, 


275 


and  degree  proportionate  to  the  characteristics  and  gravity  of  the 
primary  disease,  and  no  practical  advantage  is  to  be  gained  by  a 
separate  description  of  each  of  these  secondary  inflammations  as 
if  it  w^ere  a  different  malady.  Nor  does  it  seem  necessary  to 
recognise  as  distinctive  diseases,  varieties  of  submucous  inflam- 
mations dependent  on  the -nature  of  the  infiltration.  It  is  quite 
otherwise  with  the  laryngitis  associated  with  syphilis,  tubercle, 
etc.,  in  which  the  etiology,  pathology,  and  the  whole  course  of 
the  malady  are  of  such  a  specific  nature  as  to  demand  distinct  con- 
sideration, and  quite  special  methods  of  treatment.  But  between 
simple  non-specific  and  specific  inflammations  there  comes  a 
class — the  exudative  or  membranous — which  may  be  considered, 
to  some  extent,  common  to  both,  including,  as  it  does,  simple 
membranous  laryngitis  (croup),  which  may  be  idiopathic  or  trau- 
matic, and  diphtheria,  which  is  distinctly  specific. 
The  following  is  the  proposed  arrangement : 

A.  Simple,  Non-specific  Inflammations. 

I.  Of  the  Mucous  Membrane. 

1.  Acute. 

2.  Subacute. 

3.  Chronic. 

II.  Of  the  Submucous  Tissue  {oedema), 

1.  Acute. 

2.  Chronic. 

III.  Of  the  Perichondrium  and  Cartilages. 

1.  Acute. 

2.  Chronic. 

B.  Exudative  or  Membranous. 

1.  Idiopathic  {true  croup), 

2.  Traumatic. 

3.  Specific  {diphtheria), 

C.  Specific. 

I.  Syphilitic. 

1.  Secondary. 

2.  Tertiary. 

3.  Congenital  and  hereditary. 

II.  Tuberculous. 
III.  Lupoid. 

D.  Neoplastic. 

1.  Benign. 

2.  Malignant, 

18 


276  DISEASES  OF  THE  THROAT  AND  NOSE. 

And  to  terminate  the  category  of  laryngeal  diseases,  we  slialt 
finally  consider  the  neuroses  of  this  region. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

TITLE  OF  WORK  REFERRED  TO. 

271 
273 

273 
274 
274 

274 

I 

2 

3 
4 
5 
6 

Klein. 

TURCK. 

Navratil. 
Stockman, 
rosenstirn, 

FlKENTSCHER. 

Jf/as  of  Histology.  London. 
/  Klinik  der  Kehlkopj h-ankJieiten,  p.  402. 
V    Vienna,  ib86. 

/ Laryn^ologiscJie  Bcilrcige^  p.  18,  Leipzig, 
I  i«7i. 

British  Medical  Journal,  Dec.  4,  1886. 
/ Kossbaclis  Fharviakolog.  Untersclnuig.., 
\    ii.,  p.  78.  1876. 

Inaugural  Dissertation.  Erlangen,  1 87  7. 

CHAPTER  XIIL 


INFLAMMATION  OF  THE  MUCOUS  MEMBRANE  OF 
THE  LARYNX. 

I.  ACUTE  LARYNGITIS. 

Synonyms. — Mucous  laryngitis  ;  Catarrhal  laryngitis.  (Figs.  48 
and  49,  Plate  VI.) 

Acute  inflammation  of  the  lining  membrane  of  the  larynx 
differs  in  no  particular  from  that  of  any  other  mucous  surface, 
except  inasmuch  as  may  be  due  to  the  varying  relations  of  tension 
and  thickness  of  the  different  portions  of  the  subjacent  struc- 
tures. This  influence  is  exercised  to  a  less  extent  in  the  mucous 
than  in  the  submucous  variety  of  inflammation. 

The  disease  has  also  some  features  of  distinction  according  to  the 
age  at  which  the  attack  occurs.  It  is  decidedly  a  more  dangerous 
malady  in  children  than  in  adults ;  happily  it  is  far  less  frequent. 
An  attempt  has  been  made  by  some  authors  to  treat  the  laryn- 
gitis of  children  as  a  separate  affection,  on  account  of  certain 
differences  in  its  morbid  anatomy.  Such  differences  are  believed 
by  m^e  to  be  due  to  the  greater  tendency  in  the  young  to  plastic 
exudation  as  a  result  of  simple  mucous  inflammations,  of  which 
thrush,  aphtha,  and  plastic  bronchitis  may  be  cited  as  examples, 
and  not  to  any  definite  pathological  changes  distinctive  from 
those  of  a  laryngitis  when  exhibited  in  a  person  of  full  age. 
Probably,  however,  the  small  size  of  the  larynx  in  the  child  may 
also  influence  the  severity  of  infantile  laryngitis. 

Etiology. — As  the  most  commonly  accepted  name  implies, 
catarrhal  influence  is  the  strongest  predir.ponent  of  this  form  Oi 
laryngitis.  The  general  circumstances  which  give  rise  to  the 
catarrhal  state  have  been  fully  dwelt  on  in  Chapter  VIII.,  and 
need  not  be  again  enumerated  as  applied  to  mucous  laryngitis ; 
but  in  considering  the  various  predisposing  and  exciting  causes  of 
catarrh  as  it  may  affect  the  larynx,  it  is  necessary  to  keep  always 


278 


DISEASES  OF  THE  THROAT  AND  NOSE. 


in  view  its  two  most  important  functions — that  of  respiration  and 
that  of  vocahzation.  The  duty  of  the  epiglottis  in  deglutition 
is  hardly  at  all  affected  in  simple  catarrhal  inflammation,  and 
need  not  therefore  enter  into  present  consideration. 

It  is  generally  stated  that  the  exciting  causes  of  a  mucous 
laryngitis  are  similar  to  those  which  lead  to  the  oedematous 
form,  only  that  they  are  modified  by  the  intensity  of  the  factor, 
or  by  action  on  a  system  less  receptive  of  the  baneful  influence. 
Successive  authors,  following  their  predecessors,  have  taken  no 
trouble  to  ascertain  whether  the  nature  of  the  *  cold-catching,'  or 
catarrhal  factor,  has  any  influence  on  the  character  of  the  resulting 
inflammation ;  and  we  thus  find  the  same  atmospheric  and  hygienic 
causes  ascribed  indiscriminately  as  predisponents  or  excitants  of 
every  variety  of  laryngitis.  In  attempting  to  differentiate  them, 
I  do  not  venture  to  speak  dogmatically,  since  my  views  are  offered 
rather  as  suggestive  reflections  on  past  experience,  for  future 
correction  or  confirmation  by  others,  than  as  the  ascertained 
results  of  systematized  investigation. 

First  in  importance  amongst  the  causes  of  mucous  laryngitis 
are  the  atmospheric,  the  principal  of  which  is  the  inspiration  of 
moist  cold  air,  especially  by  those  who  habitually  breathe  through 
the  mouth,  or  in  the  subjects  of  temporary  nasal  stenosis.  ^Gott- 
stein  considers  that  *  no  mucous  membrane,  except  that  lining  the 
nose,  is  so  prone  to  inflammation,  as  a  result  of  climatic  influences, 
as  that  of  the  larynx.'  I  quite  agree  with  this  opinion,  with  the 
modification  that  the  major  proportion  of  laryngeal  catarrhs  are  the 
direct  result  of  nasal  obstruction,  and  that  propagation  of  acute 
inflammation  from  the  nose  to  the  larynx  is,  in  my  view,  second 
only  in  frequency  to  the  direct  inspiration  of  noxious  atmospheres 
by  the  mouth.  I  am  inclined  to  doubt  whether,  as  generally 
stated,  a  laryngeal  catarrh  ever  really  ascends  to  the  nose,  giving 
rise  to  a  secondary  nasal  catarrh.  Differing  from  generally  accepted 
statements,  I  have  not  found  that  exposure  to  keen  winds,  the  in- 
spiration of  dry  cold  air,  or  of  hot  air,  or  of  changes  from  heat  to 
cold,  unaccompanied  by  moisture,  act  specially  as  etiological  factors 
of  catarrhal  laryngitis. 

The  influence  of  wet  clothing,  of  body  or  feet,  is  the  next  hygienic 
cause  commonly  assigned ;  but  its  direct  influence  in  producing  a 
laryngitis  rather  than  a  rheumatism  or  any  other  form  of  inflam- 
mation is  often,  though  not  invariably,  regulated  by  certain 
functional  circumstances.  It  is  not  always  necessary  for  the 
individual  to  have  been  using  his  voice  during  the  time  of  ex- 
posure, but  a  laryngitis  will  preferably  occur  as  a  result  of  such  a 


ACUTE  LARYNGITIS, 


279 


factor  in  one  whose  profession  necessitates  much  use  of  the  larynx 
in  speaking  or  singing,  especially  if  nasal  respiration  is  impeded. 

The  following  case  illustrates  the  influence  of  exposure  to  damp 
and  the  retention  of  wet  clothing  as  conducing  to  laryngitis,  with 
but  very  slight  predisposing  circumstances  of  excessive  functional 
activity  of  the  larynx  : 

Major  C,  of  the  Royal  Engineers,  consulted  me  by  the  advice  of  Mr.  Pittock,  of 
Margate.  He  had  come  home  after  long  service  in  the  Bengal  Presidency,  on  sick  leave 
from  Indian  fever,  travelling  by  vi^ay  of  America.  He  had  suffered  for  some  time  from 
pharyngeal  irritation,  which  vi^as  increased  by  taking  cold  after  walking  under  the  Falls 
of  Niagara,  when  he  was  freely  besprinkled  with  water.  He  thinks  he  may  have  shouted 
a  little  to  make  his  voice  heard  over  the  noise  of  the  falls;  but  not  till  next  day  did  he 
suffer,  when  he  felt  increase  of  the  throat  irritation,  and  spoke  with  a  hoarse  voice.  With 
a  day  or  two  of  careful  nursing  he  was  quite  convalescent.  He  arrived  home,  and  a  few 
weeks  later  went  to  Scotland,  when  a  more  serious  relapse  occurred.  This  was  brought 
about  by  the  checking  of  heavy  perspiration,  induced  by  a  long  walk  across  the  hills,  at 
the  end  of  which  he  commenced  fishing.  Although  he  was  protected  from  wet  in  wading, 
he  fek  a  distinct  chill,  to  be  followed  the  next  day  by  acute  inflammation  of  the  larynx, 
from  which  he  suffered  for  several  weeks.  When  I  saw  him  the  disease  had  become 
subacute. 

And  next,  as  to  use  of  the  voice  as  a  cause  of  laryngiti':^. 
Doubtless  functional  activity  of  the  larynx,  leading  to  hyperaemia 
of  its  mucous  lining,  may  add  to  a  certain  extent  as  a  predisponent ; 
but  a  careful  analysis  of  a  number  of  cases  has  assured  me  that 
the  atmosphere  in  which  the  patient  has  spoken,  and  especially 
the  method  of  his  elocution,  are  far  more  important  factors,  and 
that  the  immunity  of  the  individual  to  attacks  is  in  proportion  as 
these  conditions  are  favourable  to  functional  health.  In  this  way 
may  be  explained  another  frequently  assigned  predisponent — 
previous  attacks — these  occurring  especially  in  the  case  of  those 
in  whom  the  importance  of  the  above-named  circumstances  is 
either  unrecognised  or  neglected. 

The  following  case,  which  recently  occurred  in  my  practice,  is 
a  typical  illustration  of  an  almost  everyday  experience  in  this 
direction : 

Mr.  A.,  aged  31,  had  used  his  voice  but  moderately  in  public  till  May,  1885,  when 
he  became  a  candidate  for  a  seat  in  Parliament.  He  had  never  had  instruction  in  elocu- 
tion, and  was  called  on  to  speak  at  meetings  twice  or  thrice  a  week.  In  October  he 
endeavoured  to  address  a  gathering  of  5,000  to  6,000  in  a  covered  drill-shed.  He  was 
sensible  from  the  commencement  that  he  had  a  difficulty  to  reach  his  audience.  He 
therefore  shouted  with  all  his  force.  The  result  was  that  he  felt  his  voice  go  before  he 
was  half  through  his  speech.  He  was  hoarse  the  whole  of  the  rest  of  the  campaign,  till 
his  election  in  December,  when  he  placed  himself  under  treatment  of  a  specialist,  who 
told  him  he  had  *  strained  his  vocal  cords.'  His  voice  did  not  entirely  recover  till  after  a 
course  of  two  or  three  months  of  bi-daily  inhalations,  and  almost  daily  insufflations,  com- 
bined with  absolute  rest  of  the  organ.  Another  election  campaign  was  commenced  in 
June,  and  his  voice  served  him  well  until  attendance  at  a  small  meeting — not  more  than 
600  or  70Q— in  a  gas-lighted  and  ill- ventilated  hall.    Here  he  sat  for  an  hour  and  a  half 


DISEASES  OF  THE  THROAT  AND  NOSE. 


before  his  turn  to  speak  arrived,  and  again  he  felt  his  voice  fail  him,  and  a  sense  o! 
fatigue  after  a  comparatively  short  address.  He  drove  home — twelve  miles — in  a  closed 
carriage,  with  open  window.  The  next  day  his  voice  was  fairly  well,  but  the  day  follow- 
ing it  was  quite  gone.  As  soon  as  he  was  able  to  leave  his  room  he  came  to  town,  and 
was  seen  by  me.  The  larynx  was  still  in  a  state  of  subacute  inflammation,  with  consider- 
able pharyngeal  congestion  and  relaxation. 

In  almost  all  cases  of  laryngitis  a  low  state  of  the  system  is  a  pre* 
disponent  cause,  and  constitutes  one  explanation  of  the  frequency 
of  laryngeal  and  pulmonary  inflammations  incurred  after  exposure 
at  funerals ;  the  grief  and  depression  of  bereavement,  following  in 
some  cases  on  long  and  anxious  watching,  having  weakened  the 
powers  of  resistance  against  noxious  exciting  causes. 

An  example  of  this  nature  presented  itself  in  the  person  of 

Mr.  L.,  aged  50,  a  schoolmaster,  who  having,  since  the  age  of  15,  been  engaged  in 
teaching,  had  for  many  years  suffei'ed  from  slight  throat  trouble  in  winter  and  a  frequent 
feeling  of  vocal  fatigue,  from  which,  however,  he  had  always  recovered  after  a  summer 
holiday  spent  in  his  native  air  of  Wales.  A  severe  attack  of  laryngitis  quickly  followed 
return  to  work  after  a  vacation,  which  had  been  occupied  entirely  in  nursing  a  sister  and 
a  mother  through  fatal  illnesses. 

A  constitutional  defect  in  assimilation  and  a  previous  low 
vitality  are,  of  course,  recognised  as  predisposing  to  all  forms  of 
laryngeal  inflammation,  and  it  only  remains  to  point  out  that 
such  a  state  may  be  cultivated  by  '  overcoddling '  the  body ;  this 
being  quite  as  possible  in  the  adult  as  in  the  child. 

Laryngitis  is  more  frequent  in  the  male  sex  than  the  female, 
and  in  those  of  full  age  than  in  childhood.  On  the  other  hand,  as 
previously  stated,  the  disease  is  of  greater  gravity  in  the  child  than 
in  the  adult.  Independently  of  that  most  important  influence — 
professional  use  of  the  voice — occupation  predisposes  to  laryngeal 
catarrh  in  relation  to  the  ventilation  of  the  workroom  and  the 
variation  in  the  temperature  and  other  characteristics  of  the 
atmosphere,  the  irritation  of  chemical  fumes,  noxious  gases,  and 
all  forms  of  dust  acting  as  direct  causes.  The  more  detailed 
observations  under  the  heading  of  occupation,  which  were  given 
when  enumerating  the  causes  of  pharyngitis  (p.  166)  may  be 
applied  to  the  affection  under  present  consideration.  The  same 
may  be  said  of  the  influence  of  alcoholism,  tobacco  smoking,  and 
other  dietary  faults  and  excesses. 

Of  the  exanthemata  and  continued  fevers  which  predispose  to 
mucous  laryngitis,  the  principal  are  measles,  variola,  scarlatina, 
and  typhoid.  In  the  first-named,  laryngeal  inflammation  may  be 
an  early  complication  of  the  general  disorder.  In  the  others  it  is 
a  later  manifestation,  and  not  unfrequently  of  a  more  serious 
type.  The  laryngitis  of  chicken-pox  and  rotheln  is  always  that  of 
the  mild  catarrhal  type.    Of  traumatic  causes,  irritant  poisons, 


ACUTE  LARYNGITIS, 


scorching  flame,  scalding  water  and  steam,  are  capable  of  inducing 
either  the  cedematous  or  the  mucous  form,  and  provided  the  effect 
be  quickly  counteracted,  the  inflammation  may  be  of  the  milder 
character.  With  children  there  is  usually  membranous  exudation 
(croup). 

Pathology. — The  morbid  changes  of  the  laryngeal  mucous 
membrane  in  simple  laryngitis  consist,  in  the  first  instance,  in  an 
active  hypersemia,  leading  to  swelling  of  the  tissues,  and  resulting 
in  disorder  of  the  mucous  secretion.  As  a  rule  the  inflammation 
is  spread  uniformly  over  the  whole  of  the  tissues  of  the  larynx 
(Fig.  48,  Plate  VI.);  degrees  of  severity  depending  rather  on 
differences  of  grade  than  of  extent.  But  it  sometimes  happens 
that  an  acute  catarrh  is  strictly  limited  to  quite  special  regions, 
whilst  the  rest  of  the  larynx  remains  to  all  appearance  entirely 
or  comparatively  normal  (Fig.  49).  Thus  Tiirck,  Ziemssen,  and 
Stoerk  all  speak  of  an  epiglottitis,  an  arytenoiditis,  and  a  chorditis  as 
■special  affections.  These  distinctions  have  also  been  adopted  by 
Cohen.    They  are  of  no  particular  practical  value. 

At  the  commencement  of  the  inflammatory  process  the  secretion 
is  somewhat  arrested,  and  consists  of  a  glairy  fluid,  rich  in  mucin, 
and  containing  few  epithelial  cells.  Later,  the  secretion  becomes 
more  abundant,  and  conveys  large  masses  of  epithelial  detritus. 
Before  the  infiltration  causes  desquamation  of  the  epithelium,  the 
individual  cells  become  white  and  opaque,  constituting  the  con- 
dition known  as  cloudy  swelling.  This  appearance  is  not  due  to 
hypertrophy  of  the  epithelium,  as  occurs  in  the  condylomata  lata 
of  syphilis,  but  is  caused  by  the  rapid  decay  of  the  new  cells 
generated  under  increased  blood-pressure,  and  to  granular  changes 
in  the  contents  of  the  epithelial  cells  themselves.  When  in  the 
course  of  the  affection  the  deeper  layers  are  also  thrown 
off  in  patches,  the  red,  angry  sub-epithelium  is  exposed. 
Whether  it  is  justifiable  to  call  such  erosions  ulcers,  I  will 
not  attempt  to  decide,  although  the  term  is  applied  by  many 
pathologists  to  any  loss  of  substance  upon  a  free  surface 
occurring  from  a  non-traumatic  cause.  ^Schroetter,  although 
he  speaks  of  a  loss  of  epithelium  in  acute  laryngeal  catarrh, 
denies  the  occurrence  of  ulceration  in  this  affection.  It  is 
certain  that  ulceration  extending  through  the  whole  thickness  of 
the  mucous  membrane,  as  is  the  case  in  tuberculosis,  syphilis,  etc., 
never  happens  in  simple  catarrhal  laryngitis.  I  expressed  this 
conviction  in  my  first  edition,  and  would  draw  attention  in  sup- 
port of  this  view — adversely  commented  upon  by  more  than  one 
reviewer,  but  which  further  experience  has  only  strengthened — that 


282 


DISEASES  OF  THE  THROAT  AND  NOSE. 


^Isambert,  ^Mandl,  and  many  other  French  writers  upon  laryngeal 
diseases  are  of  opinion  that  ulcerations  never  occur  in  the  larynx, 
except  in  individuals  of  some  specific  diathesis  (tuberculosis, 
syphilis,  scrofula,  etc.).  The  fissura  mucosa  which  ^Stoerk  de- 
scribes must  be  a  rare  phenomenon,  since  it  is  not  mentioned  by 
any  other  writer,  nor  has  it  ever  been  witnessed  in  my  own  prac- 
tice. He  explains,  that  should  an  erosion  happen  at  this  point — 
the  inter-arytenoid  space — it  is  quite  easy  to  understand  how  the 
break  in  continuity  may  extend  entirely  through  the  membrane, 
because  just  in  this  place  is  the  membrane  often  infiltrated  and 
oedematous,  and  being  thrown  into  folds  at  each  expiration,  and 
immediately  afterwards  put  upon  the  stretch  by  the  succeeding 
inspiration,  is  apt  to  yield  under  this  alternate  stretching  and 
relaxing ;  moreover,  he  argues,  this  region  seems  to  be  the  pars 
minoris  resistentice  of  the  larynx,  and  is  a  favourite  seat  of  the 
destructive  processes  which  invade  that  organ. 

In  children  the  morbid  process  is  somewhat  intensified,  the 
exudation  having  a  greater  tendency  to  be  plastic  or  pseudo- 
membranous (truly  croupous),  with  a  disposition  to  paresis  of  the 
muscular  tissues  and  peri-infiltration  of  the  nerve  terminations^ 
Infantile  laryngitis  is  invariably  accompanied  by  considerable 
spasm  and  stridor  of  respiration. 

In  the  laryngitis  of  measles,  the  hyperaemia  occurs  in  patches 
of  varying  intensity,  and  the  epithelium  is  exuded  irregularly  ; 
these  modifications  partaking  of  the  cutaneous  characteristics  of 
the  primary  affection.  Erosions  are  more  common  than  in  un- 
complicated catarrhal  laryngitis,  and  (rarely)  small  ulcers  are 
formed.  Membranous  exudations,  wrongly  called  *  true  diph- 
theria,' occasionally  occur  in  severe  cases. 

The  laryngitis  of  variola  is  in  mild  cases  of  the  simple  mucous 
form  ;  but  in  those  of  more  severe  grade  very  serious  laryngeal 
complications  may  arise  in  the  shape  of  pustules,  haemorrhages, 
abscesses,  fibrinous  deposit,  perichondrial  changes,  with  ulcera- 
tion and  caries.  Considering  the  frequency  of  so-called  diphtheria 
in  the  laryngitis  of  small-pox,  it  is  surprising  how  rarely  witnessed 
is  muscular  impairment  as  a  sequel.  When  such  occurs,  it  is 
generally  permanent,  and  is  far  more  likely  to  be  due  to  anchylosis 
of  the  crico-arytenoid  articulations  than  to  exist  as  a  paralysis  of 
the  nature  commonly  accepted  as  post-diphtheritic. 

Laryngitis  in  scarlatina  is  rare,  and  especially  so  in  view  of  the 
frequency  of  pharyngeal  complications.  The  laryngeal  inflam- 
mation may  be  of  moderate  grade  and  of  the  simple  mucous 
form,  or  partake  of  the  pseudo-diphtheritic  character  manifested 


ACUTE  LARYNGITIS, 


2S0 


wherever  the  septic  influence  of  these  specific  fevers  is  exerted 
with  mahgnity.  When  renal  compHcations  arise,  the  laryngeal 
condition  is  often  of  the  nature  of  acute  oedema. 

Laryngitis  usually  occurs  as  a  late  manifestation  of  typhoid 
fever,  and  more  rarely  in  connection  with  typhus.  It  may  be  of 
the  simple  mucous  variety,  or  oedematous.  The  chief  character- 
istic is  the  strong  tendency  to  active  ulcerations,  these  principally 
occurring  on  the  epiglottis,  though  all  portions  of  the  larynx  may 
be  attacked. 

In  these  diseases  also  perichondrial  changes  of  the  gravest 
character  occur. 

Symptoms  :  A.  Functional. — ^Voice  is  altered  at  an  early  stage, 
and  is  an  almost  constant  symptom,  though  the  extent  to  which 
it  is  affected  varies  with  the  degree  of  inflammation  of  the  larynx 
generally,  and  especially  of  the  vocal  cords.  The  change  usually 
commences  with  roughness  and  hoarseness,  and  a  tendency  to 
the  production  of  occasional  falsetto  and  shrill  notes  as  from 
increased  tension.  Sometimes,  on  the  other  hand,  the  voice 
appears  abnormally  bass  in  quality.  It  quickly  becomes  quite 
aphonic,  and  its  exercise  is  in  all  cases  fatiguing,  and  sometimes 
painful.  The  cause  of  the  vocal  symptoms  first  enumerated  may  be 
irritation  of  the  superior  laryngeal  nerve,  but  the  paretic  condition 
of  the  cords,  which  is  almost  always  observed  in  the  advanced 
stages,  is  no  doubt  mechanical  in  its  origin,  and  due  to  congestion 
of  all  the  tissues  and  to  inflammation  of  the  articulations  ;  later, 
possibly  to  loading  of  the  cords  by  mucous  deposits.  In  children 
the  vocal  symptoms  are  often  not  observed  until  after  the  occur- 
rence of  respiratory  evidences. 

Laryngeal  respiration  is  unembarrassed  in  adult  patients, 
except  in  severe  cases,  and  is  generally  a  symptom  that  the  inflam- 
mation is  extending  to  the  more  serious  condition  of  cedema.  The 
character  of  the  dyspncea  of  mucous  laryngitis  is  mainly  one  of 
spasm,  inspiratory  prolongation  and  stridor ;  these  generally 
decrease  as  mucous  expectoration  occurs.  In  children  the  respi- 
ratory symptoms  are  much  more  severe,  and  in  some  cases  are 
the  first  evidences  of  the  attack.  They  present  all  the  spasmodic 
characters  of  croup.  The  paroxysms,  as  in  all  croupous  attacks, 
generally  occur  at  night,  the  child  awaking  from  sleep  with 
violent  cough,  stridor,  and  all  the  other  sensations  and  appear- 
ances of  suffocation.  After  a  time  the  spasm  subsides,  and  the 
little  patient  falls  into  an  uneasy  sleep,  to  be  again  awoke  after  a 
varying  interval  by  a  repetition  of  these  alarming  and  distressing 
symptoms.  (See  '  Croup,'  Chapter  XVI.)  Nasal  respiration  is 
nearly  always  interfered  with  by  antecedent  or  concomitant  hyper- 


284 


DISEASES  OF  THE  THROAT  AND  NOSE. 


trophic  conditions  of  the  turbinated  bodies  or  septum,  or  by 
adenoid  growths. 

Cough  is  by  no  means  a  constant  symptom,  and  is  often 
hmited  to  effort  at  expulsion  of  the  supposed  cause  of  the  uncom- 
fortable sensation  of  dryness,  itching,  and  irritation  of  the  larynx, 
which  is  an  early  and  frequent  symptom;  when  it  exists  in  a  more 
pronounced  form  it  indicates  lodgment  of  secretion  at  a  cough 
spot,  or  it  may  be  the  result  of  extension  of  the  inflammation 
down  the  pharynx,  which  gives  rise  to  irritation  of  the  posterior 
wall  of  the  larynx  and  trachea.  The  cough  of  laryngitis,  when 
severe,  is  of  a  characteristic  metallic  stridulous  sound  in  the 
earlier  stages ;  while  later  its  tone  partakes  of  the  vocal  changes 
peculiar  to  the  case,  and  may  be  hoarse,  aphonic,  high  pitched  or 
low.  As  exudation  occurs,  the  spasmodic  character  subsides,  and 
the  cough  becomes  loose  and  moist.  Although  frequently  violent, 
the  cough  of  laryngitis  is  not  often  painful  in  the  adult,  but  it  is 
distressingly  so  in  the  case  of  children ;  the  little  patient  will  cry 
with  the  pain  during  an  attack,  and  may  be  seen  to  seize  his  neck  as 
if  to  prevent  it  being  torn  by  the  violence  of  the  expiratory  effort 
to  dislodge  the  tenacious  secretion. 

The  expectoration  in  adults  is  at  first  scanty  and  clear,  freer  and 
of  mucous  character  in  the  early  stages  of  subsidence.  Frothy, 
muco-purulent  and  abundant  expectoration  gives  evidence  that 
the  inflammation  is  extending  to  the  bronchi.  Expectoration  in 
children  is  always  scanty,  and  it  is  on  this  account,  probably,  that 
the  paroxysms  of  cough  are  so  much  more  severe  and  prolonged. 

Deglutition,  unless  the  laryngeal  attack  be  complicated  with 
pharyngeal  inflammation,  is  not  often  affected.  In  other  circum- 
stances there  is  not  unfrequently  a  distinct  uneasiness  experienced 
if  food  be  taken  unduly  hot  in  temperature,  as  it  impinges  on  the 
epiglottis  or  against  the  arytenoids,  on  entry  to  the  gullet. 

Pain  is  a  symptom  of  very  varying  intensity  in  adults,  but 
does  not  always  indicate  the  degree  of  inflammation.  At  first  the 
sensation  is  one  of  irritation,  tickling,  or  burning  within  the 
larynx,  soon  to  be  followed  by  a  feeling  of  tightness  and  constric- 
tion. External  tenderness  on  touch  is  not,  in  my  experience,  a 
frequent  accompaniment  of  mucous  laryngitis.  In  children  pain 
is  more  constant  and  more  severe. 

B.  Physical  Signs  are  to  be  observed  with  the  laryngoscope. 
Colour  is  always  increased,  as  would  be  expected  where  there  is 
intense  capillary  hyperasmia ;  but  the  shades  of  coloration  greatly 
vary,  according  to  the  intensity  of  the  attack.  The  vocal  cords 
are  often  the  last  parts  to  be  changed  in  colour,  and  may  have  a 
normal  appearance,  with  even  a  high  degree  of  inflammation. 


ACUTE  LARYNGITIS. 


Sometimes,  on  the  other  haad,  they  are,  from  the  first,  mor(  ^ 
less  red,  and  may  become  ahnost  purple,  and  assume  a  deeper 
hue  than  any  other  part  of  the  larynx.  In  laryngitis  of  the 
exanthemata  the  characteristics  of  the  cutaneous  eruption  are 
often  visible  in  the  pharyngo-laryngeal  region  (Fig.  51,  Plate 
VI.).  Form  is  not  often  greatly  altered  in  mucous  laryngitis, 
the  only  parts  hable  to  change  by  tumefaction  being  the  ventri- 
cular bands.  These  may  be  swollen  to  such  an  extent  as  to 
quite  obstruct  the  view  of  the  cords.  The  epiglottis  may  lose  its 
sharp  outline,  but  is  seldom  much  thickened  in  simple  laryngitis, 
except  from  traumatic  causes,  when  it  is  often  swollen. 

Ziemssen  has  drawn  attention  to  the  fact  that,  independently  of 
the  inflammation,  the  laryngeal  image  is  influenced  by  the  parti- 
cular character  of  the  muscular  paresis.  The  most  usual  varieties 
are  those  delineated  in  Plate  X.,  Figs.  98  and  99  ;  and  here 
reproduced.    The  first  (Fig.  CXXIII.)  is  due  to  impairment  of 


CXXIIL  cxxiv.  cxxv. 

Fig.  CXXIII.— Paralysis  of  Thyro-arytenoidei  in  Laryngitis. 
Fig.  cxxiv.— Paralysis  of  Arytenoideus  in  Laryngitis. 
Fig.  cxxv.— Imperfect  Approximation  of  Vocal  Cords  in  Laryngitis,  due 
TO  Swelling  and  Puckering  of  Inter-arytenoid  Tissue. 

the  thyro-arytenoidei  interni,  by  which  the  cords  are  imperfectly 
tensed ;  the  second  (Fig.  CXXIV.)  to  paralysis  of  the  arytenoideus 
transversus,  which  gives  rise  to  a  gaping  of  the  cords  at  their 
posterior  portion.  The  arytenoid  cartilages,  and  with  them  the 
vocal  cords,  may  also  be  prevented  from  approximating,  especially 
at  their  posterior  part,  by  swelling  of  the  mucous  membrane  of 
the  posterior  glottic  commissure,  as  seen  in  Fig.  CXXV. 

Surface  Texture  is,  as  indicated  when  discussing  the  morbid 
anatomy,  liable  to  be  roughened  by  separation  and  denudation  of 
the  epithelium,  leading  to  erosions  ;  but  true  ulceration  is  rare. 
In  the  laryngitis  of  the  exanthemata  and  continued  fevers,  there 
are  certain  surface  changes  characteristic  of  the  primary  afl'ec- 
tions,  and  superadded  on  those  due  to  the  inflammation.  These 
have  been  already  described. 


286 


DISEASES  OF  THE  THROAT  AND  NOSE, 


Secretion,  at  first  entirely  arrested,  afterwards  becomes  exces- 
sive in  the  form  of  clear  effusion  of  mucine.  This,  as  the  case 
progresses,  increases  in  quantity,  and  is  poured  out  as  mucus  or 
muco-pus. 

C.  External. — There  is  tenderness  and  sometimes  even  pain 
on  palpation  and  pressure,  but  external  inflammatory  alteration 
in  form  or  colour  is  comparatively  rare  ;  nor  are  the  neighbouring 
glands,  though  sometimes  painful,  often  enlarged. 

Where,  as  in  young  children,  a  satisfactory  laryngoscopic 
examination  cannot  always  be  made,  introduction  of  the  finger 
into  the  larynx  has  been  recommended  as  an  aid  to  diagnosis ; 
but  such  a  course  is  to  be  deprecated,  and  in  any  circumstance 
should  be  employed  sparingly.  In  every  instance  a  laryngoscopic 
examination  should  be  attempted ;  and  it  is  surprising  how  much 
aid  even  a  very  slight  view  will  prove  towards  forming  a  correct 
judgment ;  especially  will  it  be  so  where  there  is  the  least  reason 
to  suspect  the  presence  of  false  membrane. 

General. — An  attack  of  acute  laryngitis  seldom  occurs  without 
premonitory  chill,  and  is  almost  always  ushered  in  by  general 
febrile  symptoms,  the  pulse  being  frequent  and  strong,  and  the 
temperature  increased.  In  many  cases  loss  of  voice  and  discom- 
fort are  the  first  indications  of  an  attack. 

Commemorative. — -There  is  frequently  a  decided  family  predis- 
position to  attacks  of  catarrh,  though  the  manifestation  may  not 
be  always  laryngeal.  The  parents  of  many  young  patients  will 
often  be  found,  on  inquiry,  to  have  themselves  suffered  in  early 
life.  Previous  attacks  render  the  patient  liable  to  a  recurrence  of 
the  malady,  the  main  causes  of  which  liability  to  repetition  have 
already  been  discussed. 

Differential  Diagnosis. — This  is  not  difficult  if  the  laryngeal 
mirror  be  employed  ;  the  only  diseases  that  can  be  compared 
with  acute  laryngeal  inflammation  being  laryngismus  stridulus 
and  diphtheria.  Mistakes  in  diagnosis  are  more  probable  and 
excusable  in  the  case  of  children  than  with  adults. 

Prognosis,  Course,  and  Termination. — The  forecast  of  an 
acute  catarrhal  laryngitis  is  always  favourable  so  far  as  life  is 
concerned  ;  but  the  sudden  character  of  an  attack  often  gives  rise 
to  a  not  unwarrantable  fear  that  the  disease  may  take  on  a  graver 
character.  When  an  accurate  diagnosis  is  made,  and  treatment 
adopted  early,  the  attack  is  often  entirely  subdued  in  four  or  five 
to  ten  days.  But  too  frequently,  however,  the  gravity  of  the 
malady  is  not  recognised,  and  the  disease  drifts  into  a  subacute 
stage,  and  thence  becomes  chronic.  This  is  especially  liable  to 
occur  when  functional  causes  are  neglected. 


ACUTE  LARYNGITIS. 


2o7 


A  mucous  laryngitis  may  extend  to  the  trachea  and  bronchi,  or 
it  may,  under  certain  conditions,  especially  when  manifested  as  a 
secondary  complication,  take  on  the  more  severe  form  of  acute 
oedema. 

Treatment  :  General. — In  all  cases  I  advise  administration 
of  a  calomel  purge  at  the  commencement ;  and  when  the  pulse  is 
full  I  push  this  drug  steadily,  both  by  internal  administration  in 
small  and  frequent  doses,  combined  with  James's  and  Dover's 
powder,  and  by  inunction  with  mercurial  ointment.  In  adults, 
after  the  purge,  aconite  in  one-drop  doses  is  of  great  value 
(Form.  86).  Emetics  are  not  recommended,  but  both  in  the 
adult  and  the  child  small  doses  of  antimony,  with  ipecacuanha 
and  saline  febrifuges,  are  of  service.  When,  as  the  disease  ad- 
vances, secretion  is  poured  out,  the  process  may  be  favoured  by 
mild  expectorants  (Form.  89).  Ice  and  ice-drinks  are  very 
agreeable  to  some  palates,  while  in  other  cases  warm  emulcents 
are  preferred.  But  after  a  clearance  of  the  primae  vise,  internal 
therapeutic  measures  resolve  themselves  into  the  expectant.  The 
only  indication  to  active  medication  is  the  existence  and  intensity 
of  cough,  which  should  be  checked  and  modified  by  opiates. 
These  are  better  administered  in  very  small  quantities — HLj.  to 
in^iij.  of  solutions  of  morphia,  repeated  with  frequency — than  in 
larger  doses  at  longer  intervals.  Opiates  to  the  extent  of  narco- 
tism should  not  be  given  to  children. 

Locally,  everything  should  be  done  to  change  those  conditions 
most  favourable  to  the  causation  of  the  disease.  For  this  purpose 
the  room  must  be  kept  at  an  equal  temperature  of  not  less  than 
65°  F.,  be  shielded  from  draughts,  and  charged  with  steam.  In 
the  case  of  children,  steam  from  a  kettle,  or  a  Lee's  inhaler 
(p.  105)  playing  near  to  their  mouths,  or  wrung-out  hot  flannels 
hung  in  the  same  situation,  will  aid  to  this  end.  In  the  adult, 
the  frequent  inhalation  from  an  apparatus  causing  the  least  effort, 
of  steam  combined  with  volatile  ingredients  of  a  soothing  or 
anodyne  character,  should  be  constantly  employed.  Benzoin, 
chloroform,  conium  or  hop,  are  the  best  remedies  for  this  purpose 
(Form.  29,  30,  34,  and  37).  Counter-irritation  by  blisters  or 
blistering  fluids,  venous  depletion  by  leeches,  and  the  internal 
application  of  caustic  solutions,  are  all  excluded  from  my  practice. 
Poultices  and  compresses  are  soothing,  but  are  superseded  in  my 
more  recent  practice  by  the  application  of  continuous  cold  by 
means  of  the  Leiter  Coil  (p.  119).  Topical  remedies,  in  the  shape 
of  insufflation  or  solutions  to  be  applied  by  the  surgeon,  are 
seldom  necessary,  or  even  advisable.    Gottstein,  with  reason. 


288 


DISEASES  OF  THE  THROAT  AND  NOSE. 


makes  an  exception  *  in  those  cases  in  which,  early  in  the  disease, 
a  paretic  condition  of  the  cords  exists,  and  in  which  the  aphonia 
13  out  of  proportion  to  the  swelhng.  Here  the  stimulation  pro- 
duced by  the  insufflation  of  a  powder  composed  of  equal  parts  of 
alum  and  sugar  of  milk,  or  by  painting  once  (with  an  astringent), 
is  sufficient  immediately  to  remove  the  aphonia ;  there  afterwards 
remains  a  slight  huskiness,  due  to  the  injection  of  the  vocal  cords, 
which  usually  disappears  without  any  further  treatment.'  Finally, 
I'n  all  cases  where  there  is  intra-nasal  or  naso-pharyngeal  disease, 
these  areas  must  receive  appropriate  treatment  for  the  reduction 
of  congestion  and  obstruction — the  one  by  menthol-sprays  and 
ointments,  the  other  by  cautery.  The  rapid  cure  of  many  cases 
of  laryngitis  by  treatment  of  these  conditions  alone  will  be  nothing 
less  than  a  revelation  to  those  who  have  treated  the  affection  on 
the  old  lines. 

Dietetic  and  Hygienic— There  is  nothing  particular  to  be  said 
with  regard  to  the  dietetic  treatment  of  acute  laryngitis.  The 
administration  of  stimulants  may  be  necessary  if  the  strength  is 
failing,  but  is  not  often  employed  in  my  own  practice. 

Hygienic  treatment  during  the  attack  is  of  the  greatest  import- 
ance, and  no  chance  should  be  given,  by  exposure  to  draughts,  for 
the  recurrence  of  those  relapses  the  liability  to  which  is  so  great. 

For  many  weeks,  indeed,  caution  must  be  exercised  with 
reference  to  night  air,  heated  atmospheres,  much  use  of  the  voice, 
and  sudden  changes  in  clothing.  Seeing  how  frequently  tuber- 
culosis takes  its  origin  from  an  acute  inflammatory  attack,  as 
well  as  from  neglect  of  chronic  inflammation,  it  behoves  the  prac- 
titioner to  watch  the  patient  carefully  till  all  functional  and 
physical  signs  of  inflammation  have  subsided,  and  not  to  hesitate, 
if  necessary,  to  recommend  change  to  a  more  genial  climate. 

The  prophylactic  indications  against  recurrence  are  of  a  totally 
different  nature  in  the  case  of  patients  in  whom  an  attack  has 
been  induced  either  by  over-care  of  themselves  or  by  enforced 
confinement  in  an  impure  atmosphere.  In  such,  gradual  education 
of  the  body  and  of  the  respiratory  passages  to  more  vigorous 
treatment  and  to  a  freer  indulgence  in  open-air  exercise  will  be 
naturally  suggested. 

In  the  case  of  public  speakers,  clergymen,  and  singers,  complete 
rest  of  the  voice  should  be  rigorously  enjoined  until  recovery  is 
complete,  and  permission  to  resume  its  use  should  be  withheld 
until  the  surgeon  has  satisfied  himself  that  it  is  employed  in 
obedience  to  right  physiological  principles  of  production.  By 
observance  of  this  hint,  recurrence  in  the  class  most  liable  thereto 
may  more  surely  be  prevented  than  by  any  other  measure  of 
drug  or  hygiene. 


SUBACUTE  LARYNGITIS, 


289 


2.  SUBACUTE  LARYNGITIS. 

In  considering  the  course  and  progress  of  acute  mucous  laryn- 
gitis it  has  been  stated  that  the  affection  seldom  presents  symptoms 
of  vital  danger ;  and  it  has  only  to  be  added  that  there  is  a  form  of 
laryngitis  very  commonly  seen,  w^hich  is  recent  in  character  and 
presents  true  evidences  of  inflammation  above  and  beyond  that  of 
mere  hypersemia,  but  w^hich  is,  nevertheless,  subacute  in  intensity. 
There  is  no  necessity  to  gc  over  the  w^hole  ground  of  the  pathology, 
symptoms  and  treatment  as  just  detailed,  further  than  to  say  that 
while  the  morbid  conditions,  functional  and  physical  signs,  and 
therapeutic  measures  of  the  graver  malady  require  to  be  modified 
in  the  milder  inflammations,  the  caution  must  be  added  that  neg- 
lect of  a  subacute  catarrh  of  the  larynx  may  easily  lead  to  a 
serious  inflammation  or  to  its  continuation  in  the  chronic  form 
next  to  be  considered. 

3.  CHRONIC  LARYNGITIS. 

Synonym. — Chronic  laryngeal  catarrh.  (Figs.  50,  52  and  53, 
Plate  VL) 

Laryngitis  chronica,  by  far  the  most  frequent  form  of  laryngeal 
disease  with  which  the  specialist  has  to  deal,  differs  widely  from 
the  acute  inflammation,  both  in  its  pathological  and  clinical 
aspects.  The  condition  may  occur  as  the  sequel  of  a  more 
serious  form  of  acute  inflammation,  or  it  may  be  exhibited  from 
the  first  in  all  the  subacute  manifestations  which  characterize  it. 
In  such  circumstance  it  is  often  an  extension  of  a  similar  variety 
of  pharyngitis.  In  fact,  the  two  are  most  frequently  found  in 
association,  and  are  often  the  result  of  mouth-breathing  Induced  by 
nasal  stenosis.  There  is,  moreover,  a  form  of  laryngeal  hyper- 
asmia  occurring  especially  in  voice-using  subjects  of  catarrhal  dis- 
position, which,  while  not  reaching  to  an  inflammatory  stage,  is 
so  slightly  remittent  as  to  be  considered  essentially  chronic.  This 
has  been  already  considered  (p.  272). 

Etiology. — The  diathetic  and  atmospheric  causes  of  chronic 
laryngitis  are  essentially  those  producing  in  some  people  naso- 
pharyngeal catarrh,  and  in  others  chronic  pharyngitis,  except  that 
in  the  laryngeal  affection,  excessive  use  of  the  voice  during  the 
catarrhal  exacerbations  naturally  acts  more  injuriously  on  the 
vocal  organ.  This  condition  is  especially  common  in  those  who 
not  only  use  their  voice  at  all  times  and  seasons,  irrespective  of 
their  state  of  health,  but  who,  when  they  speak,  '  do  not  mind 
their  stops.'  It  is,  therefore,  more  common  in  extempore 
preachers,  and   still  more  in  those  who  allow  themselves  to 

19 


290  DISEASES  OF  THE  THROAT  AND  NOSE. 

become  greatly  excited,  and  to  violently  gesticulate  during  their 
harangues.  Continued  use  of  the  voice  in  the  case  of  boys  during 
*  cracking '  or  *  breaking,'  is  liable  to  render  permanent  the  in- 
flammation always  present  during  the  period  of  change. 

Excessive  smoking  is  undoubtedly  an  exciting  cause  of  chronic 
congestion,  and  is  especially  so  recognised  by  French  laryngolo- 
gists,  who  describe  at  length  certain  appearances  peculiar  to  *  la 
gorge  des  fumeurs.'  Increased  experience  has  assured  me  that 
use  of  tobacco  has  much  more  obnoxious  effect  on  the  larynx 
than  I  formerly  believed ;  but  I  am  still  of  opinion  that  its  ill- 
effects  are,  in  many  cases,  confined  to  the  pharynx,  where  it  is 
particularly  harmful  to  those  who  while  smoking  indulge  in  fre- 
quent expectoration.  So  far  as  the  larynx  is  concerned,  that 
organ  is  affected  by  direct  irritation  only  in  as  much  as  it  is  a 
portion  of  the  respiratory  tract ;  this  is  equally  true  of  other 
impure  atmospheres,  such  as  those  in  which  miners,  knife- 
grinders,  millers  and  masons  are  obliged  to  work ;  the  effect  of 
these  influences  on  the  voice  is,  as  it  were,  an  anatomical  coinci- 
dence. Occupations  which  necessitate  working  in  an  atmosphere 
charged  with  noxious  particles  are  not  thought  to  greatly  influence 
this  complaint ;  they  probably  predispose  to  more  serious  disease. 

The  habit  of  taking  *  chasses '  of  cognac,  absinthe,  and  other 
liqueurs,  helps  to  produce  congestion  and  inflammation  of  the 
epiglottis,  and  this  extends  into  the  larynx.  Without  doubt  the 
victims  of  chronic  alcoholism,  especially  when  spirit-drinkers,  suffer 
very  frequently  from  chronic  laryngitis.  In  both  these  classes  of 
smokers  and  topers,  the  cause  of  the  inflammation  is  twofold; 
first,  by  paralysis  of  the  vaso-motor  control,  and  secondly,  in  the 
case  of  drunkards,  as  suggested  by  Gottstein,  from  accumulation  of 
the  profuse  mucus — characteristic  of  alcoholism — which,  dropping 
during  sleep  from  the  pharynx  into  the  larynx,  sets  up  irritation  in 
the  air-passages.  That  the  power  of  alcohol  to  cause  chronic 
laryngitis  is  due  to  local  as  well  as  to  systemic  causes,  is 
evidenced  by  the  fact  that  the  same  condition  may  be  witnessed 
in  wine-merchants  and  wine-tasters,  who,  notwithstanding  their 
occupation,  may  be  very  temperate  in  drinking  and  careful  not  to 
swallow  the  fluid.  Chronic  laryngitis  is  not  infrequently  witnessed 
as  a  sequel  of  measles  and  other  exanthemata,  even  in  cases  in 
which  acute  laryngeal  inflammation  may  not  have  been  manifested. 

The  presence  of  morbid  growths  is  also  asserted  to  be  a  cause 
of  this  condition,  but  it  might  more  properly  be  classed  as  an 
effect. 

When,  however,  enlarged  bronchial  glands  or  other  tumours 
press  upon  the  recurrent  nerve,  even  to  a  slight  extent,  there  is 


CHRONIC  LARYNGITIS. 


291 


frequently  laryngeal  hypersemia.  It  is  a  question  whether  this  be 
not  due  to  irritation  of  the  sympathetic  interfering  with  the  vaso- 
motor supply.  Patients  of  the  arthritic  diathesis,  and  also  those 
hable  to  haemorrhoids,  and  other  affections  due  to  congestion  of 
the  portal  system,  frequently  suffer  from  catarrhal  laryngitis. 

It  is  a  moot-point  as  to  how  far  an  elongated  uvula  is  responsible 
as  a  factor  in  the  production  of  chronic  laryngeal  inflammation, 
but  it  is  suggested  that  the  two  conditions  may  be  simultaneously 
■or  successively  produced  by  one  exciting  cause,  which  is  usually 
hypertrophic  nasal  catarrh.  There  can  be  no  doubt  that  chronicity 
of  laryngeal  inflammation  is  sometimes  due  to  uvular  irritation. 

The  disease  is  essentially  one  of  adult  hfe,  and  is  naturally, 
having  regard  to  the  circumstances  favourable  to  its  causation, 
more  frequent  in  males  than  in  females. 

Pathology. — This  affection  is  marked  by  a  permanent  dilata- 
tion of  the  vessels,  due  to  a  long-standing  hyperaemia,  and  a 
hypertrophy  of  the  mucous  membrane  in  all  its  layers,  and  to  a 
•change  in  mucous  secretion.  ^Tobold  reports  a  case  in  which  the 
hypertrophy  of  the  ventricular  bands  was  so  great  as  to  obliterate 
the  pouches  of  Morgagni,  and  to  conceal  entirely  from  view  the  true 
■cords.  Such  a  grade  of  thickening  is,  however,  comparatively 
rare,  and  seldom  occurs  in  simple  catarrh.  In  chronic  blennor- 
rhcea  and  the  throat  affections  of  typhoid  patients  the  mucous 
membrane  is  sometimes  seen  to  be  thrown  into  such  thick,  heavy 
folds  as  to  render  the  larynx  almost  unrecognisable.  ^Lewin  states 
that  such  a  condition  is  not  unusual  in  the  chronic  sore  throat  of 
preachers  and  criers.  The  glands  and  glandules  especially  par- 
take of  the  general  hypertrophy,  and  give  to  the  membrane  a 
granular  appearance — laryngitis  granulosa,  otherwise  called  folli- 
cular laryngitis. 

^Tiirck  first  described  and  figured  a  peculiar  form  of  chronic 
inflammation  limited  to  the  vocal  cords,  which  he  often  observed 
in  professional  singers,  and  to  which  he  has  given  the  name  Chorditis 
iuberosa,  A  number  of  such  cases  have  occurred  in  my  practice  in 
v/hich  the  appearances  agreed  exactly  with  the  description  given 
by  this  author.  Whilst  the  other  regions  of  the  larynx  seem  quite 
normal,  the  cords  are  of  a  yellowish-red  colour,  and  upon  their 
superior  surface,  usually  near  the  free  margin,  appear  little  white 
tumours  or  granulations  varying  from  the  size  of  a  millet-seed  to 
that  of  a  small  pea.  According  to  the  experience  of  ^Mandl,  in 
chronic  laryngitis  the  inflammation  is  commonly  seen  to  be  con- 
fined to  the  arytenoids  and  vocal  cords  in  singers  and  orators,  and 
to  the  epiglottis  and  ary-epiglottic  folds  in  drinkers  and  smokers, 
an  experience  with  the  first  portion  of  which  I  entirely  agree.  In 


292 


DISEASES  OF  THE  THROAT  AND  NOSE. 


advanced  cases  of  alcoholic  laryngitis,  if  the  term  may  be  used^ 
the  hypersemia  and  thickening  are  general. 

Erosions,  chiefly  upon  the  cords  and  between  the  arytenoids,  are 
much  more  frequently  met  with  in  chronic  than  in  acute  catarrh. 
Such  loss  of  epithelium  is  not  readily  noticed  by  other  than  the 
experienced  laryngoscopist,  who  recognises  this  condition  not  so 
much  by  the  change  in  colour  as  by  the  absence  of  that  peculiar 
sheen  which  the  epithehum,  covered  with  mucus,  lends  to  these 
parts  in  the  normal  larynx.  Catarrhal  erosions  heal  readily  by 
quick  regeneration  of  epithelial  cells,  and  the  loss  of  substance 
never  extends  beyond  the  uppermost  layer  of  the  mucous  mem- 
brane, being  usually  small  in  extent  and  circular  in  shape. 

Symptoms  :  A.  Functional. — The  Voice  is,  as  a  rule,  chron- 
ically  hoarse ;  the  amount  of  dysphonia,  however,  varies  consider- 
ably, according  to  the  degree  of  inflammation  of  the  cords,  and 
also  after  functional  rest  or  exertion  :  under  injurious  influences 
it  may  become  aphonic.  Food-taking  will  often  improve  it ;  and 
another  factor  of  variation  of  functional  purity  is  the  time  of  the 
day.  Thus  a  patient  will  arise  with  the  throat  dry  and  with 
distinct  hoarseness.  After  breakfast  the  voice  may  be  compara- 
tively clear,  to  become  again  quite  hoarse  after  some  hours  of 
use,  or  as  the  effect  of  bodily  fatigue.  If  the  patient  sings,  the 
vocal  injury  will  be  manifested  in  loss  of  range,  diminished 
endurance,  and  want  of  control.  As  the  disease  advances,  all 
vocal  efforts  will  be  obviously  strained  and  laboured. 

Respiration  is  seldom  embarrassed,  but  the  respiratory  act  be- 
comes less  complete,  so  to  speak,  on  account  of  the  fatigue  of  the 
glottis.  In  the  act  of  phonation,  therefore,  the  vocal  cords  are  not  set 
in  action  by  full  bellows-power,  and  breath-taking  during  speech  be- 
comes frequent  and  gaspy.  Nasal  respiration  is  usually  impeded. 

Cough  is  a  frequent  but  by  no  means  constant  symptom,  unless 
the  catarrh  has  extended  to  the  trachea  and  bronchi.  It  most 
often  occurs  on  rising  in  the  morning,  on  change  of  atmosphere,, 
on  use  of  the  voice,  or  under  any  circumstances  liable  to  facilitate 
the  dislodgment  of  mucus  in  the  air- passages.  The  cough,  also,, 
is  of  two  kinds,  one  a  moist  cough,  when  the  mucus  is  excessive, 
but  not  deficient  in  fluid  qualities ;  the  other  ringing  and  metallic, 
to  be  noticed  in  advanced  cases  in  which,  the  secretion  having 
become  dried  and  tenacious,  has  rendered  the  cords  harsh,  and 
has  crippled  muscular  and  articular  movements. 

Pain. — Except  in  the  effort  of  vocal  exertion  or  after  fatigue, 
there  is  rarely  true  pain.  There  is,  however,  a  constant  feeling 
of  constriction,  or  as  if  there  were  a  foreign  body  in  the  air* 


CHRONIC  LARYNGITIS. 


293 


passages.  When  the  uvula  is  elongated,  direct  irritation  may 
play  some  part  in  giving  rise  to  this  sensation. 

B.  Physical. — Colour. — The  hypersemia  of  chronic  laryngitis 
is  by  no  means  uniform.  The  congestion  of  the  vocal  cords  may 
be  unilateral,  or  may  be  limited  to  the  cartilaginous  portion.  In 
the  latter  case  the  vocal  process  will  be  seen  to  stand  out  as  a 
w^hite  prominence :  the  other  parts  of  the  larynx  are  congested 
in  proportion  and  frequency  to  the  closeness  of  adhesion  of  the 
mucous  membrane  to  the  subjacent  tissue ;  viz.,  the  epiglottis, 
the  cartilages  of  Wrisberg  and  of  Santorini,  and  the  ventricular 
bands ;  and  they  are  usually  affected  in  the  order  named. 

The  capillary  vessels  of  the  epiglottis  are  often  seen  to  be  in  a 
state  of  varicose  congestion,  similar  to  that  in  chronic  pharyngitis. 
A  case  in  which  there  was  a  similar  condition  of  the  vocal  cords 
and  ventricular  bands  has  been  described  by  ^^Morell-Mackenzie, 
and  has  been  termed  by  him  Phlebectasis  laryngea.  It  is  exceed- 
ingly rare,  and  hardly  merits  the  dignity  of  being  considered  as  a 
separate  disease  or  variety.  In  this  opinion  I  am  supported  by 
Von  Ziemssen,  ^^Duchek,  Duncan  Gibb,  Gottstein,  and  most 
other  authorities. 

Form  and  Texture. — Although  there  may  be  swelling  of  the 
mucous  membrane,  especially  of  the  looser  portions,  absence  of 
submucous  thickening  is  a  marked  characteristic  of  chronic 
catarrhal  laryngitis,  to  which  may  be  added  immunity  from  ulcera- 
tion. The  epiglottis  is  the  only  part  likely  to  be  at  all  thickened, 
this  especially  in  the  laryngitis  of  alcoholism. 

There  is  commonly  relaxation  of  the  inter-arytenoid  fold  and 
of  the  ventricular  bands,  and  the  vocal  cords  are  often  seen 
during  phonation  to  have  lost  co-ordinative  power,  and  to  be 
spasmodic  in  action,  giving  a  jerkiness  of  movement. 

Very  rarely  indeed  there  may  be  slight  erosion  at  the  vocal 
process  (Fig.  52) ;  i.e.  at  the  situation  where  friction  may  be 
-exercised ;  but  such  a  symptom  should  be  looked  on  with  the 
greatest  suspicion  of  deeper  mischief.  Another  situation  for 
-erosions  is  the  inter-arytenoid  fold.  The  follicles  of  the  larynx 
are  sometimes  enlarged  and  prominent  (Fig.  53).  Some  writers 
then  consider  the  disease  as  a  separate  variety,  viz.,  follicular 
laryngitis,  or  glandular  laryngitis. 

My  opinion  on  this  point  is  the  same  as  that  enunciated  con- 
cerning varieties  of  chronic  pharyngitis,  viz.,  that  all,  being  due 
to  one  pathological  cause,  should  be  considered  as  variations  in 
degree,  and  not  of  kind  ;  but  when  there  is  any  distinct  enlarge- 
ment of  the  racemose  glands,  and  especially  if  there  be  superadded 
erosion,  however  slight,  of  the  vocal  cords,  the  practitioner  should 


294 


DISEASES  OF  THE  THROAT  AND  NOSE. 


search  carefully  for  signs  of  general  phthisis.  Comparison"  of 
Fig.  53  in  Plate  VI,,  and  of  Fig.  72  in  Plate  VIII.,  will  show 
how  enlargement  of  the  glandules  may  be  but  a  iirst  step  towards 
tuberculous  ulceration.  I  entirely  agree  with  Gottstein,  who  says 
that  it  is  doubtful  whether  the  small  red  points  sometimes  seen 
on  the  vocal  cords  in  chronic  catarrh  bear  any  analogy  to  glandular 
pharyngitis,  and  for  one  reason,  because,  as  is  well  known,  such 
glands  are  entirely  absent  from  the  upper  surface  of  the  cords. 
This  author's  suggestion  that  these  red  points  are  to  be  considered 
as  papillary  enlargements,  which,  under  certain  circumstances, 
are  the  origin  of  polypi,  is  also  one  of  great  probability. 

Mobility  is  often  impaired,  both  from  mechanical  obstructioa 
to  articular  action  and  by  slight  muscular  pain. 

The  changes  in  this  direction  are  usually,  but  not  uniformly,, 
bi-lateral. 

Secretion. — This  may  be  abundant  or  sparse  ;  it  is  almost 
always  excessive  in  the  earlier  stages,  but  often  becomes  gradually 
arrested  as  the  disease  advances  ;  so  that  the  throat  is  felt  and 
seen  to  be  always  dry.  The  character  of  the  secretion  generally 
is  that  of  a  gelatinous  accumulation,  with  viscid,  tenacious  mucus 
clinging  about  and  around  the  laryngeal  orifice,  and  collecting  in 
thick  pellets  upon  the  cords  and  in  the  ventricles. 

The  little  bridges  of  mucus  stretching  from  cord  to  cord,  which  - 
are  seen  during  phonation,  are  almost  in  themselves  sufficient  to  ' 
differentiate  a  chronic  from  an  acute  catarrh. 

C.  Miscellaneous. — External  examination  gives  but  negative- 
results,  though  the  surgeon's  attention  is  often  drawn  by  the 
patient  to  a  supposed  swelling.  When  any  glandular  enlarge- 
ment is  present,  there  is  strong  reason  to  doubt  the  simple  nature 
of  the  complairrt.  The  general  health  suffers  in  very  varying 
degree ;  this  variation  depending  much  upon  the  importance  of 
the  loss  of  voice  to  the  material  well-being  of  the  patient,  and  its 
consequent  effect  on  his  nervous  system. 

The  digestive  system  is  frequently  disturbed,  causing  loss  of 
appetite  and  dyspepsia.  Worry  and  mental  anxiety  will  often 
produce  sleeplessness,  and  even  emaciation.  Careful  examination 
of  the  lungs  should  never  be  omitted  in  any  case  of  chronic 
laryngitis,  especially  when  there  is  persistent  swelling  of  any  part 
of  the  mucous  lining,  or  when  there  is  ulceration. 

Prognosis,  Course,  and  Termination. — Recovery  from  this 
disease  is  always  slow,  and  greatly  depends  upon  the  amount  of 
obedience  to  the  practitioner's  directions,  and  the  perseverance 
with  which  they  are  carried  out. 

The  great  cause  of  anxiet}'  is  the  fear  of  a  simple  catarrh 


CHRONIC  LARYNGITIS. 


395 


running  into  the  tubercular  form.  On  this  account  the  prognosis 
should  be  guarded,  especially  if  there  be  the  slightest  tendency  to 
phthisis  in  the  patient's  family.  As  a  rule,  with  persistence  of 
treatment,  these  cases  do  well.  When,  however,  the  catarrhal 
predisposition  is  strongly  marked,  the  tendency  to  relapse  is  great. 
This  cause  will  be  found  to  exert  an  influence  on  associated  en- 
largement of  the  cervical  or  bronchial  glands.  In  cases  of  goitre 
there  will  often  be  a  marked  exacerbation  on  the  recurrence  of 
the  menstrual  flow. 

In  many  instances,  however,  the  baneful  cause  will  have  pro- 
duced so  much  mischief,  that  the  voice  will,  in  spite  of  all  treat- 
ment, remain  hoarse.  This  is  the  case  when  the  disease  is  due 
to  chronic  alcoholism,  and  where  abuse  of  the  voice  has  been  very 
exaggerated.  Vocalists,  if  they  regain  their  voice,  but  too  fre- 
quently find  that  the  range  is  diminished,  and  the  tone-quality 
impaired. 

Treatment:  General. — Constitutional  remedies  are  not  of 
much  service,  though  attention  to  the  digestion,  diet,  and  general 
powers  of  the  patient  is  of  decided  importance. 

In  many  cases  where  the  mental  anxiety  has  almost  gone  the 
length  of  hypochondriasis,  bromide  of  potassium  has  proved  of 
great  utility  in  my  practice.  In  other  cases  5-grain  doses  of 
hydrate  of  chloral  two  or  three  times  a  day  have  an  admirable 
effect  in  calming  the  mind.  When  there  is  portal  congestion,  a 
natural  saline  purgative  draught  each  morning  is  beneficial.  In 
glandular  enlargements  and  goitre,  iodide  of  iron  and  other 
suitable  remedies  must  be  given,  and  cod-liver  oil  will  also  be 
indicated  where  there  is  any  sign  of  general  emaciation. 

Local. — Local  measures  must  be  directed  to  favouring  resolu- 
tion. First  amongst  these  are  vapour  inhalations  of  a  stimulating 
character.  Benzoin  with  pine  oil,  benzole,  creasote,  and  pine  oil, 
or  pine  oil  with  camphor,  are  the  best ;  the  first  being  the  mildest, 
the  others  successively  stronger  in  stimulant  action  (Form.  31, 
35>  39>  and  40).  This  list  of  stimulating  inhalations  is  quite 
long  enough  for  all  practical  uses.  Obstnictlons  in  the  nose,  so 
frequently  present,  are  to  be  radically  removed  ;  for  mere  palliation 
will  not  lead  to  complete  cure  or  protect  against  recurrence. 

Lozenges,  whether  the  pharynx  be  or  be  not  affected,  are  also  of 
great  benefit,  those  in  Form.  12,  16,  and  17  containing  astringents, 
together  with  sialagogues  and  expectorants,  being  the  best  adapted 
to  fulfil  the  various  indications.  When  pharyngeal  disease  co- 
exists, the  treatment  of  such  a  condition  is  considered  of  primary 
importance,  and  very  many  cases  of  laryngeal  congestion  will  get 
quite  well  with  but  httle  further  treatment  when  the  co-existent 
disease  higher  up  has  been  cured. 


296 


DISEASES  OF  THE  THROAT  AND  NOSE: 


The  use  of  local  astringent  solutions  is  of  decided  value,  espe* 
cially  when  there  is  congestion  of  the  vocal  cords,  arytenoid 
cartilages,  or  inter-arytenoid  folds.  Such  solutions  should  be  of 
very  moderate  strength :  the  most  generally  serviceable  is  that  of 
chloride  of  zinc,  10  to  30  grains  to  the  ounce  of  water,  and  the 
application  must,  of  course,  be  made  by  the  surgeon  himself,  with 
the  aid  of  the  laryngeal  mirror  (Form.  65). 

It  is  worse  than  useless  to  allow  such  a  measure  to  be  attempted 
by  any  lay  friends  or  relations  of  the  patient. 

Von  Ziemssen  advises  the  use  of  the  soHd  nitrate  of  silver  (!!), 
and  of  solutions  of  that  salt  to  the  strength  of  240  grains  (!)  to  the 
ounce  of  water.  In  no  case  of  congestion  is  even  a  mild  solution 
of  the  silver  salt  superior  to  one  of  zinc,  aluminium,  or  iron 
(Form.  65,  59*,  and  62);  and  the  spasm  exceptionally  characteristic 
as  a  result  of  lunar  caustic  applications,  is  highly  detrimental  in 
a  disease  where  rest  to  the  organ  is  an  all-important  factor  in 
treatment. 

Beyond  these  objections,  I  have  long  believed  that  applications 
of  nitrate  of  silver  to  inflamed  surfaces  have  the  effect  of  inducing 
hyperplasia ;  so  much  so,  that  whenever  I  have  found  in  cutting 
a  tonsil  that  the  tissue  was  unusually  dense  and  gristly,  I  have 
suspected  a  long  course  of  such  treatment,  and  on  inquiry  my 
suspicions  have  generally  been  confirmed.  My  colleague,  Dr. 
Orwin,  reports  to  me  a  case  strongly  supporting  this  view  in 
regard  to  their  influence  on  the  larynx,  which  he  recently  saw  in 
Buda-Pesth,  under  the  care  of  Dr.  Irsai : 

It  was  that  of  a  male  patient,  aged  40,  who  had  long  suffered  from  chronic  laryngitis, 
which,  during  the  last  three  years,  had  been  treated  by  means  of  spray  applications  10 
the  larynx  of  a  10  per  cent,  solution  of  nitrate  of  silver,  with  the  result  that  not  only 
had  his  whole  body,  especially  his  face  and  hands,  undergone  characteristic  discoloration, 
but  thickening  of  the  entire  larynx  had  taken  place  to  such  an  extent  as  to  cause  dangerous 
stenosis.  For  this  condition  Dr.  Irsai  had  been  compelled  to  perform  tracheotomy,  and 
had  subsequently  widened  the  glottic  opening  by  means  of  Schroetter's  dilators. 

Application  by  the  brush  is  preferred  in  our  practice  to  the 
use  of  insufflations  or  of  sprays,  though  all  three  methods  are  em- 
ployed according  to  indications.  Mineral  astringents  are  greatly 
to  be  preferred  to  the  weaker  vegetable  solutions  of  the  same 
•character. 

As  the  congestion  subsides,  faradization  is  of  great  benefit  in 
restoring  tone  and  co-ordinative  power. 

Externally  the  application  of  wet  compresses,  and  the  nightly 
painting  with  tincture  of  iodine  over  the  thyroid  cartilage,  will  be 
found  of  value. 


CHRONIC  LARYNGITIS. 


Hygienic  and  Dietetic. — Of  primary  importance  is  a  careful 
avoidance  of  all  preventible  causes  of  the  affection.  First  and 
foremost  may  be  mentioned  rest  to  the  voice,  not  only  from  pro  - 
fessional exertion,  but  in  ordinary  conversation.  In  the  home 
circle  the  patient  should  be  directed  to  speak  alv^ays  below  his 
breath,  even  to  a  v^hisper;  to  avoid  irregular  vocal  efforts,  as 
laughing;  and,  especially,  never  to  speak  in  noisy  streets  or 
vehicles. 

Lessons  in  elocution  with  reference  to  breath-taking  are  also 
all-important.  The  patient  when  recovered  should  be  directed  to 
take  a  full  inspiration,  to  comr^ience  to  ex-spire  only  with  a 
spoken  word,  and  to  utter  at  first  only  one  word  with  each  ex- 
spiratory  effort.  Gradually  he  may  be  allowed  to  say  two  or 
three  words  on  each  breath,  and  so  to  lengthen  his  sentences  to 
the  ordinary  extent.  In  these  lessons  nothing  is  better  than  the 
Prayer-book  version  of  the  Psalms,  pointed  as  each  verse  is  into 
four  sentences  for  chanting.  These  sentences  can  easily  be  sub- 
divided and  lengthened  for  the  necessary  lessons. 

All  noxious  habits  of  smoking  and  drinking,  exposure  to  varying 
temperature,  and  the  continuance  of  hurtful  occupations,  are  to 
be  interdicted.  For  those  whose  occupations  compel  them  to  be 
more  or  less  exposed  to  cold  or  damp  atmospheres,  the  use  of  the 
respirator,  or  one  of  its  efficient  substitutes,  will  be  necessary,  and 
will  often  be  found  a  great  help  to  treatment. 

Cold  affusions  and  general  tonic  measures  are  useful  to  many, 
while  in  others  climatic  change  to  warmer  countries  will  be 
imperative. 

The  Turkish  bath,  from  its  action  on  the  skin  as  well  as  for  the 
loccil  benefit  of  the  inspired  hot,  dry  air,  is  often  of  the  greatest 
value  in  chronic  laryngeal  inflammation. 

The  diet  must  be  simple,  nutritious,  and  non-irritant.  As  a 
tonic,  a  fairly  generous  Burgundy  will  be  found  to  be  more 
easily  digested  and  more  nourishing  in  its  quality  than  the  port 
of  the  preceding  generation  or  the  claret  of  the  present  day. 

Laryngitis  Sicca. — In  advanced  cases  of  atrophic  rhinitis  and 
pharyngitis  sicca,  and  very  rarely  without  such  an  association, 
catarrh  of  the  larynx  results  in  an  exhaustion  of  the  fluid  elements 
of  the  mucous  secretion.  The  consequence  is  that  the  scales  and 
strings  of  dry,  discoloured  mucus  are  seen  to  cling  to  the 
membrane,  itself  generally  dry  and  highly  inflamed.  Efforts  to 
dislodge  the  adherent  mucus  is  often  attended  by  slight  haemor- 
rhages, but  with  temporary  improvement  to  the  voice,  which  is 
otherwise  almost  or  entirely  lost. 


298 


DISEASES  OF  THE  THROAT  AND  NOSE. 


I  have  seen  this  disorder  in  coal-heavers,  sweeps,  etc.,  and 
have  often  observed  that  atoms  of  the  impure  atmosphere  at- 
tendant on  their  calHng  are  to  be  seen  in  the  larynx.  It  is 
probable  that  when  associated  with  atrophic  rhinitis,  the  far 
larger  nasal  space  occasioned  by  the  latter  disease  favours 
inspiration  of  the  atmosphere  unfiltered  and  unmoistened,  and 
thus  directly  leads  to  inspissation  of  the  laryngeal  secretion. 

Treatment  consists  in  liquefying  emollient  sprays  (Form.  42, 
45,  49,  and  51)  and  moderately  stimulating  inhalations  (Form.  31, 
32,  and  39),  to  which  in  these  cases  addition  of  aldehyde  is 
especially  serviceable  (Form.  33).  Concurrent  treatment  of  the 
nasal  and  pharyngeal  condition  is  also  of  importance,  and  in- 
unction of  the  nostril  is  of  distinct  value  as  a  means  of  catching 
noxious  particles  of  the  atmosphere  from  falling  into  the  larynx 
(Form.  82  and  84). 

Sub-glottic  Chronic  Laryngitis  represents  a  peculiar  form 
of  chronic  laryngeal  catarrh,  to  which  attention  was  drawn  by 
such  early  observers  as  -^^Czermak  and  ^'^Tiirck,  and  of  which 
cases  have  also  been  reported  by  ^^Burow,  ^*^Gehrardt,  and 
others.  The  last-named  author  has  given  it  the  name  of 
Chorditis  inferior  hypertrophica,  because  in  the  course  of  the  disease 
hyperplasias  in  large  groups  form  in  the  inferior  cavum  of  the 
larynx,  which  may  produce  a  serious  degree  of  stenosis.  The 
Chronic  blennorrhcea  of  Stoerk,  to  which  allusion  has  been  made  in 
relation  to  its  pharyngeal  manifestation  (page  184),  gives  rise  to  a 
similar  appearance  when  it  extends  to  the  larynx,  but  is  never 
manifested  in  this  region  as  a  primary  disease  of  that  nature. 
According  to  ^^Klebs  the  cicatricial  formations  upon  the  cords 
in  blennorrhcea  are,  in  their  histological  elements,  very  Hke  those 
of  rhinoscleroma.  I  have  seen  but  one  case  of  laryngeal  rhino- 
scleroma,  and  in  this,  the  clinical  signs  and  the  laryngoscopic 
appearance  were  so  like  those  of  chorditis  inferior  hypertrophica, 
that  I  believe  the  diagnosis  would  have  been  impossible  but 
for  the  simultaneous  existence  of  the  growth  in  the  anterior 
nares. 

The  FUNCTIONAL  SYMPTOMS  are  in  the  main  vocal  and 
respiratory,  and  may  extend,  the  one  to  aphonia,  the  other  to 
suffocative  attacks  of  dyspnoea.  The  physical  signs  are,  as 
hinted,  difficult  of  exact  diagnosis,  mainly  because  it  is  not  always 
easy  to  ascertain  of  what  nature  is  the  thickening. 

Treatment  consists  in  dilatation  either  prior  or  subsequent  to 
the  performance  of  tracheotomy.  The  best  modes  of  dilating 
will  be  more  fully  described  in  the  chapter  on  *  Syphilitic  Laryn- 


CHRONIC  LARYNGITIS. 


299 


gitis,*  in  which  stenosis,  calling  for  surgical  interference,  is  a 
much  more  frequent  complication  than  of  a  simple  laryngeal 
catarrh. 

REFERENCES  TO  AUTHORITIES. 


PAGE.  NO. 


NAME. 


TITLE  OF  WORK  REFERRED  TO. 


I 

2 
3 

4 
5 

6 

7 

8 

9 
10 
II 


gottstein. 

schroetter. 

isambert. 

Mandl. 

Stoerk. 

TOBOLD. 

Lewin. 

TURCK. 

Mandl. 

Morell-Mackenzie. 
Duchek. 

GiBB. 
CZERMAK. 

TiiRCK. 

BUROW. 

Gehrardt. 
Klebs. 


op.  cit.,  p.  67. 

Beitrag  zur  Behandhmg  der  Larynx- 

stenose.    Wien,  1876. 
Op.  cit.,  p.  85. 

(Maladies  dii  Larynx  et  du  PharynXy 
\    p.  657.    Paris,  1872. 
Op.  cit.,  p.  209. 

{Laryngoscopies    etc.,   p.    182.  Berlin, 
3rd  edition,   1874.     Translated  by 
Sydenham  Society. 
VircJiow's  Archiv,  Bd.  xxiv. 
Klinik  der  Krankheiteii  des  Kehlkopfes^ 

p.  164.    Wien,  1866. 
Op.  cit.,  p.  651. 
Op.  cit.,  p.  292. 

I  'raite  de  Pathologie  Lnteme,  vol.  1. 
Diseases  of  the  Throat  and  Windpipe, 
London,  2nd  edition,  1866. 
K  Kehlkopfspiegel,    etc.     Leipzig,    1 863. 
I     Translated  by  Sydenham  Society. 
Op.  cit.,  p.  166. 

Langenbeck's  Archiv,   vol.   xviii.,  p. 
228.  1875. 
\  Dent.  Archiv  fiir  LUin.  Med.,  p.  583. 
{  1873. 

LLandbuch  Path.  Anatom.,  p.  142. 


Mi, 


CHAPTER  XIV. 

INFLAMMATION  OP  THE  SUBMUCOUS  TISSUE  OF  THE 

LARYNX. 

I.— A  CUTE. 

Synonyms. — CEdematous  laryngitis  ;  Phlegmonous  laryngitis ; 
Acute  oedema  of  the  larynx ;  (Edema  of  the  glottis. 

Serous  infiltration  of  the  submucous  tissue  is  one  of  the  gravest 
manifestations  of  acute  catarrhal  or  specific  inflammation,  and 
will  immediately  receive  consideration. 

The  condition  may,  however,  arise  as  a  simple  oedema,  quite 
independently  of  any  inflammatory  process,  and  especially  as  a 
manifestation  of  hepatic  obstruction,  malaria,  and  of  general 
dropsy,  caused  by  disease  of  kidneys,  heart,  or  lungs,  or,  according 
to  ^Von  Ziemssen,  *as  a  result  of  circumscribed  obstruction  in 
the  laryngeal  veins,  through  compression  of  the  superior  and 
inferior  thyroid  veins,  or,  further,  of  the  facial  vein,  or  even  of  the 
internal  jugular,  and  the  innominate  veins.  The  oedema  will  be 
unilateral  or  bilateral,  according  to  the  site  and  extent  of  the 
hindrance  to  the  circulation.  Such  compression  may  be  produced 
by  enlargement  of  the  thyroid  glands,  swefling  of  the  lymphatic 
and  salivary  glands,  and  new  formations  about  the  neck,  aneurisms 
of  the  aorta,  etc.*  It  is  unnecessary  to  further  allude  to  these 
lesions  than  to  say  that  relief  of  the  local  condition  is  only  of 
temporary  benefit,  unless  attention  be  mainly  given  to  the  removal 
and  alleviation  of  the  primary  cause. 

Acute  OEdema  of  the  Larynx,  as  a  complication  or  phase  of 
laryngitis,  is  a  tolerably  rare  affection.  When  occurring  it  con- 
stitutes a  very  grave  condition,  on  account  of  the  extremely 
important  influence  that  but  comparatively  slight  oedema  may 
exercise  on  performance  of  the  vital  process  of  respiration.  It  is 
probable,  as  already  hinted,  that  the  effusion  in  adults  has  its  ana- 
logue in  children  as  a  non-specific  membranous  laryngitis  or  true 
croup ;  the  difference  between  the  submucous  serous  infiltration 
of  the  one  and  the  membranous  transudation  in  the  other  being 


ACUTE  (EDEMA  OF  THE  LARYNX. 


explained  by  the  imperfect  capillary  system  of  children.  Acute 
oedema  of  the  larynx  is  seldom  witnessed  prior  to  the  age  of 
adolescence. 

^Gottstein  considers  acute  submucous  laryngitis  and  acute  serous 
I   infiltration  of  the  submucous  tissue  of  the  larynx — to  which  last 
1  only  he  gives  the  name  of  acute  oedema — as  two  separate  diseases  ; 
but  there  does  not  appear  sufficient  ground,  either  clinical  or 
pathological,  for  this  distinction. 

Etiology. — Excluding  cases  resulting  from  traumatic  causes, 
cedema  is  much  oftener  a  secondary  than  a  primary  affection. 
Among  6,062  post-mortem  examinations  made  at  the  Berlin 
Charite  between  the  years  1869-71,  ^Hoffmann  found  33  cases  of 
cedema  glottidis,  10  of  which  were  of  primary  and  23  of  secondary 
origin.  ^Sestier  found  in  igo  cases,  36  primary  and  122  secondary. 
Among  the  general  diseases  which  may  give  rise  to  oedema  glottidis, 
various  forms  of  cardiac  disease,  nephritis,  and  phthisis  are  the 
most  frequent  causes.  Gottstein  expresses  a  doubt  as  to  whether 
serous  infiltration  of  the  larynx  ever  occurs  as  a  primary  affection, 
considering  that  '  in  the  great  bulk  of  cases  it  is  a  sequel  of  local 
diseases.'  That  acute  laryngeal  cedema  is  often  preceded  by 
pharyngitis  is  true,  but  not  more  so  of  it  than  of  a  simple  catarrhal 
laryngitis.  It  is  equally  a  fact  that  it  is  exhibited  as  a  direct  com- 
plication of  more  specific  forms  of  inflammation  of  the  larynx,  as 
of  syphilis  and  tuberculosis,  of  perichondritis,  and  of  retro-pharyn- 
geal  abscess.  It  is,  moreover,  frequently  associated  with  acute 
infectious  diseases,  and  especially  with  erysipelas  and  pyaemia.  I 
have  experience  of  one  case  in  which  it  occurred  as  a  sequel  to 
ursemic  poison  in  connection  with  an  enlarged  prostate.  But 
this  only  goes  to  prove  that  any  condition  likely  to  poison  the 
i  blood-supply  is  favourable  to  the  serous  infiltration,  and  there  are 
'  ample  anatomical  causes  to  explain  the  preference  for  infiltration 
:   in  the  upper  air-passages. 

It  cannot  be  denied  that  acute  oedematous  laryngitis  frequently 
occurs  as  an  apparently  primary  affection.  Of  predisposing  causes 
a  previously  low  state  of  the  general  health  or  great  bodily  fatigue 
is  almost  invariably  to  be  observed ;  for  there  is  almost  always  a 
history  of  long  hours  of  toil,  exposure,  or  travelling.  The  exciting 
cause  may  be  induced  in  many  ways.  The  patient  sits  in  a 
draught  of  cold  air,  or  drives  or  rides  exposed  to  the  bitter  keen- 
ness of  a  north-east  wind.  Probability  as  to  the  existence  of  a 
variety  of  the  atmospheric  factor  in  the  production  of  a  catarrhal 
or  an  oedematous  laryngitis  has  been  already  alluded  to,  and  the 
following  case  is  illustrative  of  this  suggestion.  It  has  many  other 


302 


DISEASES  OF  THE  THROAT  AND  NOSE, 


points  of  extreme  interest  which  will  receive  attention  in  other 
places  more  appropriate  to  their  consideration  (see  page  313). 

F.  B.,  set.  12,  was  brought  to  me  from  Arundel  by  Mr.  Evershed  of  that  town.  The 
history  was  that  havhig  become  very  hot  through  labour  in  the  havfield  he  lay  down  to 
sleep  in  the  open  air,  exposed  to  a  hot  sun  simultaneously  with  an  east  wind.  On  awaking 
he  felt  pain  and  stiffness  in  the  neck,  which  was  followed  by  acute  inflammation  of  the 
right  side  of  the  neck  and  larynx.  Acute  oedema  with  great  stridor  followed,  and  when 
I  saw  him  at  the  end  of  three  months,  the  larynx  was  found  to  be  still  generally  inflamed, 
with  considerable  infiltration  both  supra-  and  infra-glottic.  The  right  vocal  cord  was 
also  at  that  time  immobile.  The  diagnosis  was  acute  perichondritis,  with  simultaneous 
submucous  laryngitis. 

In  some  cases  there  is  no  premonition  whatever  of  inflamma- 
tion, and  distress  due  to  infiltration  is  the  first  symptom  manifested. 
Cases  have  positively  been  reported  in  which  death  occurred 
without  any  threatening  of  the  condition  which,  on  autopsy,  was 
proved  to  be  the  cause  of  death.  Probably  in  such  circumstances 
there  exist  also  an  unrecognised  organic  disorder  of  the  circula- 
tion. 

Of  others  less  rapidly  fatal,  but  almost  equally  sudden  in 
appearance,  the  following  are  examples : 

1.  A  man  after  a  day's  work  in  a  blast-furnace,  walks  in  the  snow,  and  sits  for  hours  in 
his  damp  clothes  smoking  and  drinking  in  a  badly-ventilated,  low-pitched  taproom,  which 
he  leaves  at  a  late  hour,  again  exposed  to  the  open  air,  for  a  small  room  in  a  close  quarter 
of  the  town. 

2.  A  cabman  takes  frequent  nips  of  raw  spirit  in  a  hot  bar,  to  '  keep  out  the  cold  '  to 
which  he  is  exposed  for  the  rest  of  the  night  on  his  box. 

3.  Lastly,  a  young  man,  tired  with  office-work  during  the  day,  spends  his  evenings 
practising  glees  at  a  smoking  concert  :  he  takes,  on  leaving,  nothing  more  than  a  little 
cold  whisky  and-water,  but  goes  home  thoroughly  tired  to  bed. 

In  each  of  these  instances — all  taken  from  actual  experience — 
the  result  is  the  same ;  the  patient  awakes  from  sleep,  a  few  hours 
after  retiring  to  bed,  with  a  feeling  of  great  discomfort  in  respira- 
tion, which  speedily  increases  to  a  sense  of  intense  suffocation. 
And,  not  to  anticipate,  all  the  symptoms  of  oedema,  to  be  presently 
detailed,  are  developed  with  alarming  rapidity,  and  with  but  little 
preliminary  warning. 

Lastly,  traumatic  causes  may  produce  acute  oedema ;  such 
as  swallowing  hot  water — Cohen  mentions,  also,  extremely  cold 
water — or  inhaling  scorching  hot  air,  irritant  poisons,  caustic  ap- 
plications, and,  occasionally,  injury  produced  by  the  introduc- 
tion of  intra-laryngeal  instruments  for  operative  purposes.  In 
these  last  cases  the  effusion  is  often  purely  haemorrhagic ;  m 
others  it  is  sero-sanguineous  in  character. 

CEdema  of  the  larynx,  especially  when  of  traumatic  origin,  may 
develop  very  rapidly.    I  remember  one  case  in  which  the  left  ary- 


ACUTE  (EDEMA  OF  THE  LARYNX. 


3^3 


tenoid  had  been  wounded  by  a  small  fish-bone,  and  in  which  laryn- 
gotomy  had  to  be  done  three  hours  after  the  accident.  On 
another  occasion,  in  which  the  oedema  was  the  result  of  an  intra- 
laryngeal  operation,  I  had  to  operate  within  an  hour  of  its  origin. 

Pathology. — CEdema  of  the  larynx  consists  essentially  of 
transudation  or  infiltration,  usually  serous  or  sero-purulent  and 
sometimes  sanguineous,  into  the  submucosa.  We  have  noticed 
in  Chapter  VIII.,  page  167,  that  such  infiltration  and  its  resultant 
signs  are  modified  in  the  various  districts  of  the  larynx  by  anato- 
mical differences  in  the  thickness  and  tension  of  the  mucous 
membrane  and  submucosa ;  it  has  also  been  pointed  out  that  the 
ary-epiglottic  folds,  the  ventricular  bands,  and  the  ventricles  are 
those  structures  which  offer  least  resistance  to  infiltration. 

The  commencement  of  the  process  is  marked  by  a  slight 
reddening  of  the  mucous  membrane  with  increased  secretion, 
especially  in  the  neighbourhood  of  the  ventricles,  which  are  rich 
in  muciparous  glands.  The  parts  affected  soon  become  swollen 
and  cedematous,  and  the  membrane  grows  pale  and  assumes  a 
stretched  appearance.  When  the  ary-epiglottic  folds  become  in- 
filtrated they  grow  into  large  yellowish-red  tumours,  obliterating 
the  ventricles,  completely  cover  the  cords  and  often  produce 
stenosis  in  an  extreme  degree.  Sometimes  both,  but  oftener 
only  one  of  the  arytenoids  takes  part  in  the  inflammation  and 
infiltration,  and  may  swell  to  twice  or  even  three  times  its 
normal  dimensions ;  and  it  is  in  such  cases  that  the  rapidly 
rising  dyspnoea  develops.  When  the  epiglottis  becomes 
cedematous  it  appears  as  a  large  round  translucent  tumour, 
and  may  attain  such  dimensions  as  to  completely  block  up  the 
entrance  to  the  larynx. 

The  epiglottis  is  especially  attacked  in  those  cases  in  which 
the  laryngeal  inflammation  follows  on  a  pharyngitis.  In  oedema 
associated  with  the  specific  poisons  of  scarlet  fever,  erysipelas, 
typhus,  and  small-pox,  the  infiltration  may  extend  to  the  muscles 
and  other  tissues  of  the  neck.  In  such  cases  both  the  primary 
and  secondary  affections  are  of  the  most  virulent  form.  They  . 
partake  of  the  nature  of  phlegmonous  inflammations.  False 
membrane  is  often  formed,  and  the  disease  then  assumes  a 
pseudo-diphtheritic  character.  The  inflammation  may  be  fol- 
lowed by  ulceration,  and  may  extend  to  the  perichondrium, 
terminating  in  caries  or  in  gangrene.  The  appearances  of  an 
oedema  of  the  larynx  in  life,  and  after  death,  are  altogether 
different,  but  each  is  characteristic;  the  shrunken,  wrinkled 
membrane  seen  on  autopsy,  and  resembling  the  hand  of  a 


3^4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


washerwoman  after  long  soaking  in  the  wash-tub,  will  clearly  in- 
dicate the  prior  existence  of  swelling  due  to  effusion  even  where 
no  laryngoscopic  examination  was  made  in  life. 

The  microscopical  characters  are  such  as  would  be  naturally 
expected  from  knowledge  of  the  morbid  process.  There  is  an 
effusion  of  serum,  with,  in  most  cases,  an  escape  of  leucocytes 
into  the  meshes  of  the  connective-tissue  of  the  submucosa.  On 
supervention  of  inflammation  white  corpuscles  migrate  from 
the  vessels  in  great  excess,  and,  undergoing  fatty  degeneration, 
are  converted  into  pus-cells. 

CEdema  is  not  always  limited  to  the  supra-glottic  region,  but 
may  extend  to  infiltration  of  the  submucosa  beneath  the  vocal 
cords  (Plate  VI.,  Fig.  47).  Infra-glottic  oedema,  as  it  is  then 
called,  is  almost  invariably  secondary,  and  it  is  always  serious  ; 
the  effusion  is  slow  in  subsiding,  and  has  a  strong  tendency  to 
pass  into  the  subacute  or  chronic  stage.  We  have  alluded  at 
page  296  to  that  peculiar  form  of  chronic  inflammation  which 
has  received  the  name  of  chorditis  mferior  hypertropJiica  ;  in  point 
of  fact,  it  would  more  properly  be  considered  as  a  submucous 
inflammation,  and  was  only  mentioned  in  that  situation  because 
it  is  usually  so  discussed  by  other  authors.  The  diagnosis  of  the 
exact  character  of  sub-glottic  infiltrations  is  really  very  difficult, 
and  practically  of  not  much  influence  in  the  prognosis.  In  some 
instances  the  effusion  is  circumscribed ;  this  condition  indicates 
the  probable  formation  of  an  abscess. 

Symptoms  :  A.  Functional. — There  is  no  occasion  to  discuss 
in  detail  all  the  various  changes  in  the  performance  of  normal 
acts,  many  of  them  being  similar  to  those  observed  in  the  catarrhal 
form  of  inflammation.  It  is  to  be  remembered,  also,  that  in 
describing  the  various  symptoms  of  a  typical  inflammatory 
oedema,  many  cases  occur  in  which  there  are  no  symptoms 
whatever  prior  to  that  of  a  fatal  suffocation  or  syncope. 

The  voice  is  naturally  affected,  and  is  usually  rough  and  deep, 
or  altogether  lost,  the  alteration  being  due  to  thickening  and 
weighting  of  the  cords,  and  to  mechanical  impairment  of  normal 
muscular  contractions. 

The  respiration,  as  it  is  the  most  important  function  that  is 
affected  by  oedema,  is  also  that  which,  as  a  rule,  most  prominently 
attracts  attention,  and  calls  urgently  for  relief,  though  cases  occa- 
sionally occur,  especially  in  the  course  of  chronic  diseases  of  the 
kidneys  and  other  distant  organs,  in  which  considerable  oedema 
exists,  without  respiratory  disturbance.  A  slight  exciting  cause 
will,  in  such  circumstances,  produce  a  fatal  suffocation ;  as,  for 


ACUTE  CEDE  MA  OF  THE  LARYNX, 


instance,  in  the  patient  reported  by  Ziemssen,  and  quoted  by 
^Cohen  : 

The  man  died  within  a  few  minutes  of  entering  the  Clinic  at  Greifswalde,  from  penetra- 
tion of  the  wall  of  the  right  ventricle  of  Morgagni  by  a  sharp  piece  of  the  rib  of  a  tobacco- 
leaf.  The  patient,  who  had  come  there  on  account  of  Bright's  disease,  was  sitting  in  a 
waggon  smoking  when  he  arrived. 

The  chief  difficulty  in  breathing  in  the  early  stages  is  in  the 
act  of  inspiration,  which  is  quickly  observed  to  be  stridulous,  but 
in  many  cases  expiration  is  at  first  unaltered.  The  dyspnoea  is 
due  to  stenosis  caused  by  oedema  of  the  ventricular  bands,  or  of 
the  submucous  covering  of  the  arytenoid  cartilages.  In  rare  cases 
the  symptoms  may  be  due  to  a  similar  condition  of  the  infra- 
glottic  mucous  membrane.  As  the  disease  advances  expiratory 
distress  takes  place,  with  the  result  of  inducing  complete  apnoea. 

Cough  is  observed  in  the  acute  inflammatory  form,  but  is  short, 
incomplete,  and  unproductive.  It  is  due  to  an  endeavour  to 
remove  mechanical  impediment  to  respiration  rather  than  to  a 
desire  to  dislodge  secretion.  Occasionally  the  cough  is  spasmodic, 
resembling  in  the  adult  what  is  observed  in  the  child  during  an 
attack  of  croup.    The  act  of  coughing  is  frequently  very  painful. 

Deglutition  is  both  difficult  and  painful,  not  only  when  the 
epiglottis  is  involved,  but  also  when  the  coverings  of  the  arytenoid 
cartilages  are  infiltrated,  the  swelling  then  implicating  the  anterior 
wall  of  the  pharynx  at  its  entrance  to  the  oesophagus. 

Pain  is  a  distinct  but  by  no  means  constant  symptom.  When 
the  infiltration  extends  to  the  adjacent  tissues  of  the  neck,  dis^ 
tress  on  movement  is  naturally  increased.  When  oedema  i^ 
considerable,  the  sense  of  suffocation  is  most  oppressive.  Pain  on 
palpation  depends  somewhat  on  the  mechanical  rigidity  and 
tension  of  the  tissues  involved. 

B.  Physical. — With  the  laryngeal  mirror  oedema  is  quickly 
recognised.  When  associated  with  acute  inflammation,  the  colour 
is  very  characteristic,  the  infiltrated  portion  presenting  the  ap- 
pearance of  a  globular  semi-transparent  body,  very  bright  in  tint 
at  the  circumference.  At  other  parts  numerous  highly-injected 
capillary  vessels  will  be  observed,  especially  on  the  epiglottis.  In 
the  oedema  associated  with  disease  of  liver,  kidneys,  or  heart,  the 
coloration  is  less  intense;  it  is  increased  when  the  inflamma- 
tion is  secondary  to  acute  infectious  disorders.  The  vocal  cords  are 
invariably  of  a  deep  red  hue  in  inflammatory  oedema,  and  when 
the  effusion  is  subglottic,  the  mucous  membrane  in  that  situation 
will  almost  always  be  seen  to  be  of  a  more  intense  red  than  the 
cords  above.    Acute  oedema  of  the  vocal  cords  is  an  extremely. 

20 


3c6 


DISEASES  OF  THE  THROAT  AND  NOSE, 


rare  occurrence.  In  cases  of  haemorrhagic  effusion,  the  swelling 
is  localized,  and  is  of  a  deep  red,  the  rest  of  the  larynx  being 
entirely  or  comparatively  normal  in  form  and  hue.  The  fact  of  an 
abscess  may  be  suspected  when  a  circumscribed  soft  red  swelling, 
less  translucent  than  when  the  effusion  is  serous,  is  observed.  I 
have  never  seen  the  yellow  coloration  insisted  on  by  some 
authors  as  characteristic  of  the  presence  of  pus. 

Form  and  texture  may  be  greatly  altered  by  oedema,  which,  as 
before  stated,  may  be  general  or  partial.  Reference  to  the  plates 
will  indicate  the  great  changes  which  may  occur  in  configuration. 

The  special  changes  characteristic  of  laryngitis  associated  with 
the  exanthemata,  which  maybe  either  mucous  or  submucous,  have 
already  been  detailed  at  page  281  et  seq. 

In  scarlet-fever  the  colour  will  be  modified  in  patches  of  varying 
intensity ;  in  erysipelas  there  will  be  the  peculiar  brawny  cha- 
racter ;  in  typhus  the  mucous  membrane  will  be  dusky  ;  in  small- 
pox, pustules  will  be  visible  :  all  these  distinctive  changes  are  for 
the  most  part  to  be  seen  on  the  epiglottis.  When  the  inflamma- 
tion is  due  to  the  swallowing  of  boiling  water,  the  epiglottis  is 
more  frequently  oedematous,  and  (especially  in  young  children) 
the  whole  surface  may  be  covered  by  a  false  membrane,  which 
differs  from  that  of  croup  or  diphtheria  in  its  greater  transparency 
and  diminished  tenacity.  Irritant  poisons  often  produce  excoria- 
tions and  ulcerations,  their  gravity  and  extent,  as  also  the  cedema, 
depending  on  the  virulence  and  extent  of  the  noxious  influence. 
When  there  is  injury  from  a  foreign  body  (Fig.  54,  Plate  VI.), 
a  portion  of  the  mucous  membrane  may  be  seen  to  have  been 
denuded,  and  inflammation  will  have  commenced  at  the  seat  of 
injury. 

Alteration  ot  secretion  is  manifested  in  the  form  of  serous 
effusion  into  the  submucous  tissue,  which  may  become  sero- 
purulent  or  purulent :  this,  as  recovery  takes  place,  is  expelled  as 
a  copious  mucous  or  muco-purulent  discharge,  with,  possibly, 
sanguineous  staining. 

C.  Miscellaneous. — These  greatly  vary  according  to  the 
primary  cause  of  the  oedema,  and  have  been  already  to  a  con- 
siderable degree  indicated.  There  may  be  fever,  with  all  its 
accompanying  changes  of  pulse  and  temperature  ;  or,  as  in  sudden 
cedema  in  connection  with  chronic  diseases,  there  may  be  no 
special  symptoms  calling  for  attention.  When  once  the  oedema  is 
manifested,  the  general  effect  on  the  health  is  one  of  extreme 
depression  of  the  system.  In  all  there  are  more  or  less  pro- 
longed  periods   of  repose,   and   almost   always   there   is  an 


ACUTE  CEDE  MA  OF  THE  LARYNX, 


307 


exacerbation  of  every  symptom,  subjective  and  objective,  in  the 
night  hours. 

Diagnosis. — There  is  no  probabiHty  of  the  laryngoscopist  mis- 
taking oedema  for  any  other  laryngeal  condition.  The  only 
caution  to  be  observed  is  not  to  neglect  to  seek  for  the  primary 
cause,  evidence  of  which  may  be  hidden  or  masked  by  the  local 
changes  due  to  the  infiltration. 

Prognosis,  Course,  and  Termination. — Recovery  from  acute 
oedema  of  the  larynx  of  primary  origin  is  always  doubtful,  and 
will  be  influenced  largely  by  the  stage  at  which  it  comes  under 
treatment,  and  the  amount  of  success  attending  local  remedial 
measures  correctly  and  vigorously  adopted — that  is  to  say,  on  the 
promptitude  with  which  relief  is  afforded  to  the  mechanical 
obstruction  to  healthy  respiration.  The  forecast  of  a  secondary 
oedema  must  be  regulated  by  the  circumstances  attending  the 
primary  cause  of  the  disease.  The  duration  of  an  attack — i.e., 
the  anxious  period — may  not  last  above  three  or  four  days ;  but 
the  patient  can  hardly  be  said  to  be  out  of  danger  under  two  or 
three  weeks,  and  may  even  then  be  the  subject  of  chronic  in- 
filtration. Complications  may  arise,  as  has  been  suggested,  in  the 
lungs,  or  by  the  supervention  of  a  croup  or  pseudo-diphtheria  on 
a  simple  inflammation,  with  the  further  result  of  ulceration  or 
gangrene.  When  death  occurs,  it  is  most  frequently  due  to  car- 
bonic acid  poisoning,  but  may  be  the  direct  result  of  stenosis  or 
spasm  of  the  glottis.  Both  the  symptoms  and  the  prognosis  are 
much  more  serious  when  the  inflammatory  process  and  infiltration 
has  extended  to  the  tissues  beneath  the  glottis.  Another  source 
of  danger  is  the  possible  advent  of  suppuration — abscess  of  the 
larynx — to  which  allusion  has  already  been  made. 

Treatment  :  General. — In  mild  cases  treatment  should  be 
commenced  on  the  lines  indicated  for  mucous  laryngitis,  the 
remedies  being  modified  in  the  secondary  forms  in  accordance 
with  the  primary  cause. 

Beyond  the  promotion  of  diaphoresis  and  diuresis  by  mild 
salines,  I  do  not  prescribe  general  drug  treatment ;  but  the  cough 
often  demands  relief  by  sedatives.  Iron  is  indicated  as  a  tonic  of 
specific  value  in  many  of  the  secondary  forms.  Since  the  intro- 
duction of  pilocarpine,  I  have  found  benefit  follow  its  hypodermic 
administration  in  doses  of  from  iV  to  J  of  a  grain. 

Regulation  of  the  temperature  of  the  room,  and  the  use  of 
inhalations,  will  be  of  service  in  a  submucous  as  in  a  mucous 
laryngitis,  while  the  effect  of  applications  of  continuous  cold  by 
the  Leiter  coil  is  even  more  markedly  beneficial  in  the  cedematous 
than  in  the  catarrhal  from  of  inflammation. 


3o8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


So  soon  as  and  wherever  oedema  is  discovered,  local  scarification 
v^^ith  the  laryngeal  lancet  should  be  employed.  There  is  probably 
no  such  severe  disease  that  can  be  so  quickly  relieved  by  a  simple 
local  measure  as  can  oedema  of  the  larynx,  and  the  operation  is 
one  of  really  easy  performance  to  a  practitioner  having  but 
moderate  skill  in  the  use  of  the  laryngoscope.  The  relief  to  the 
local  distress  and  the  consequent  general  comfort  of  the  patient 
is  sometimes  little  less  than  magical. 

There  may  be  recurrence  of  the  oedema  after  scarification,  but 
the  tendency  thereto  is  diminished  by  employment  of  pilocarpine 
and  perseverance  in  use  of  the  cold  coil.  If,  in  spite  of  scarifica- 
tion and  the  other  means  recommended,  oedema  continues,  with 
consequent  increase  of  respiratory  distress,  general  enfeeblement 
and  symptoms  of  blood-poisoning,  tracheotomy  must  be  per- 
formed. When  the  disease  is  due  to  traumatic  causes,  this 
procedure  may  be  necessary  at  a  quite  early  period,  but  in 
uncomplicated  attacks  it  is  always  better  to  give  medicinal,  surgical, 
and  hygienic  remedies  a  chance.  Even  when  death  has  taken  place 
as  it  may  do  most  suddenly,  the  windpipe  should  be  opened,  and 
artificial  respiration  tried. 

Bearing  in  mind  the  liability  to  infra-glottic  oedema,  we  should 
open  the  trachea  as  low  down  as  possible.  There  is  the  possi- 
bility, in  this  form,  of  the  knife  pushing  the  swollen  mucous 
membrane  before  it,  instead  of  dividing  it,  so  that  the  trachea 
tube  passes  between  the  mucous  membrane  and  submucous  wall. 
This  is  a  serious  accident  which  has  happened  to  good  surgeons  ; 
it  will  be  best  guarded  against  by  taking  up  the  trachea  with  a 
firm  tenaculum  before  making  an  opening  into  it.  Even  after  the 
swelling  due  to  oedema  has  been  reduced,  tracheotomy  may 
become  necessary  on  account  of  paralysis  of  the  crico-arytenoidei 
postici  from  serous  infiltration. 

In  the  case  of  abscess,  incision  must  be  made  by  means  of  a 
guarded  laryngeal  knife.  The  head  of  the  patient  should  after  the 
incision  be  quickly  lowered  to  prevent,  as  far  as  possible,  the 
passage  downwards  of  the  escaping  fluid.  If  pus  is  liberated,  it  is 
quite  possible  that  there  will  be  a  temporary  exacerbation  of  the 
dyspnoea  and  cough,  to  be  followed  in  a  few  moments  by  great 
relief. 

2.  CHRONIC  SUBMUCOUS  INFLAMMATION  OF  THE  LARYNX. 
Synonym. — Chronic  oedema  of  the  larynx. 

Chronic  serous  infiltration  of  the  laryngeal  submucosa  may 
remain  after  subsidence  of  an  acute  attack,  or  it  may  complicate 


CHRONIC  SUBMUCOUS  INFLAMMATION  OF  THE  LARYNX.  309 


some  of  the  subacute  specific  diseases  of  the  larynx,  as  caries — 
the  result  of  perichondritis,  however  caused,  and  of  syphilis  and 
cancer;  but  in  my  experience  true  laryngeal  oedema  is  seldom 
witnessed  in  connection  with  tuberculosis.  In  its  chronic  form 
oedema  is  more  frequently  unilateral  than  in  the  acute ;  and  infra- 
glottic  oedema  is  almost  always  subacute  in  intensity,  and  is  very 
slow  to  subside.  Chronic  serous  infiltration  of  the  larynx  often 
exists  as  such  from  the  first,  when  occurring  in  connection  with 
the  diseases  of  circulation  and  excretion  already  mentioned  in 
our  description  of  the  acute  form ;  and  an  accidental  cold  or 
other  circumstance  will  develop  symptoms  of  alarm,  both  in  the 
intensity  of  the  degree  and  the  rapidity  of  the  manifestation. 

Pathology. — We  have  seen  that  in  the  acute  form  there  is  a 
transudation  of  serum  into  the  meshes  of  the  submucosa,  and  a 
more  or  less  extensive  diapedesis  of  leucocytes,  which,  when  not 
proceeding  to  suppuration,  become  organized  into  connective- 
tissue.  These  changes  are  for  the  most  part  .identical,  whether 
the  infiltration  be  of  the  submucosa  of  the  epiglottis,  the  inter- 
arytenoid  or  ary- epiglottic  fold,  or  of  the  tissues  beneath  the  vocal 
cords. 

Independently  of  chronic  serous  effusion  there  is  often  an 
amount  of  thickening  remaining  after  acute  inflammations  and 
attending  many  of  the  chronic  forms  of  laryngeal  catarrhs  which 
are  due  to  submucous  hyperplasia.  This  is  especially  true  of  the 
laryngitis  of  drunkards,  of  syphilis,  and  of  the  subglottic  hyper- 
trophic inflammations. 

This  submucous  thickening  when  occurring  in  the  course  of  a 
chronic  mucous  laryngitis,  especially  if  accompanied  by  local 
ansemia,  is  often  premonitory  of  tuberculous  deposit  and  breaking 
down. 

The  SYMPTOMS  of  a  chronic  oedema  or  submucous  inflamma- 
tion are  generally  those  of  the  acute  form  with  less  active  spasm, 
and  of  modified  intensity  generally. 

The  laryngoscope  reveals  the  physical  signs  of  hypertrophy 
of  the  portion  involved,  the  swelling  being  of  a  more  solid  and  less 
translucent  form  than  in  the  acute  form.  The  character  of  the 
sub-cordal  swelHng  may  be  seen  in  Fig.  19,  Plate  VIII. 

Prognosis  is  grave,  but  the  disease,  though  rarely  subsiding 
entirely,  may  be  very  slow  in  its  progress.  Treatment  is  only  of 
avail  in  so  far  as  there  may  be  a  constitutional  cause  amenable  to 
constitutional  medication.  But  when  chronic  oedema  is  associated 
with  perichondritis  but  little  is  to  be  done.  Exceptions  exist  in 
the  case  of  general  or  Hmited  laryngeal  oedema  connected  with 


DISEASES  OF  THE  THROAT  AND  NOSE. 


syphilis,  and  infra-glottic  oedema  when  it  occurs  as  a  sequel  of  an 
acute  infectious  disease,  unaccompanied  with  caries.  Scarifica- 
tion is  less  likely  to  give  relief  in  the  chronic  than  in  the  acute 
form,  because  the  effusion  is  of  a  much  more  solid  character. 
This  is  particularly  true  of  sub-glottic  infiltration.  In  this 
variety  there  is  a  hope  of  saving  life  by  early  tracheotomy — the 
windpipe  being  opened  as  low  as  possible.  The  tube  will  very 
probably  be  required  to  be  permanently  retained.  Chronic 
oedema  in  connection  with  syphilis  will  sometimes  be  relieved  by 
large  doses  of  potassic  or  sodic  iodide.  It  is  also  particularly 
amenable  to  mercury,  whether  applied  locally  over  the  region  of 
the  larynx  (Form.  79)  or  by  general  inunction. 

Stenosis  due  to  sub-cordal  infiltration  is  rarely  improved  by 
dilatation,  because  the  narrowing  is  by  thickening  of  the  lateral 
walls.  Central  stenoses  are  usually  but  not  invariably  due  tc 
syphilis,  and  their  treatment  will  be  considered  in  the  chapter 
treating  of  that  disease  as  it  affects  the  larynx. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

TITLE  OF  WORK  REFERRED  TO. 

300 

301 
301 

301 

I 

a 
3 
4 
5 

Von  Ziemssen. 

gottstein. 
Von  Hoffmann. 

Sestier. 

Cohen. 

f  Cyclopcedia    of    Medicine,    vol.  vii. 
\    London,  1876-77. 
Op.  cit.,  p.  99. 

(Edema  Glottidis.    Berlin,  1872. 
f  I'raite  de  PAngine  laryngee  ademateuse. 
\    Paris,  1852. 

Op.  cit.,  p.  445. 

CHAPTER  XV. 


INFLAMMATION  OF  THE  PERICHONDRIUM  AND  CARTILAGES 

OF  THE  LARYNX. 

(Figs.  77,  78,  79,  Plate  VIII.) 

Etiology  and  Pathology. — In  both  syphilitic  and  tuberculous 
inflammation  of  the  larynx,  and  also  in  carcinoma,  resulting  ulcera- 
tion may  extend  to  the  perichondrium,  and  may  lead  to  death  and 
dislodgment  of  a  portion  or  even  the  whole  of  a  cartilage. 

The  cartilages  of  the  larynx  may,  however,  undergo  degenera- 
tion quite  independently  of  any  of  the  dyscrasire  just  mentioned; 
and  these  changes  may  be  brought  about  in  three  ways :  (i)  by 
ossification,  proceeding  to  actual  primary  disease  of  the  cartilage; 
(2)  by  fibroid  degeneration  of  the  cartilage ;  and  (3)  by  disease 
commencing  in  the  perichondrium.  The  first  affection  is  one  of 
old  age,  and  may  or  may  not  be  accompanied  by  deposits  around 
the  articulations ;  the  second  also  occurs  generally  at  an  advanced 
period  of  life,  though  ^I  have  seen  one  case,  to  be  again  men- 
tioned presently,  of  this  disease  in  quite  a  young  girl ;  the  third  is 
due  to  traumatic  causes,  or  is  the  result  of  the  phlegmonous  in- 
flammation complicating  typhus,  erysipelas,  etc.  ^Ziemssen, 
^Stoerk,  and  ^Gerhardt  have  reported  cases  of  perichondritis  due 
to  decubitus — that  is,  to  pressure  of  the  plate  of  the  cricoid  against 
the  vertebrae  in  the  case  of  aged  persons  confined  to  their  bed,  and 
obliged  to  lie  constantly  on  their  back,  or  as  a  result  of  any  long 
illness  entailing  the  same  position.  ^  Scanes  Spicer  similarly  attri- 
butes the  liability  of  this  cartilage  to  perichondrial  changes  to  the 
circumstance  of  irritation  from  the  bolus  of  food  as  it  passes  into 
the  oesophagus. 

Most  authors  appear  to  consider  that  caries  is  a  necessary 
sequence  of  perichondrial  inflammation,  but  as  I  consider  wrongly ; 
for  in  not  a  few  cases  the  inflammation  terminates  in  resolution 
with  more  or  less  thickening  and  functional  impairment,  but 
without  caries  or  separation  of  any  portion  of  the  cartilages. 

Of  the  exciting  causes  to  the  first  variety  of  perichondrial 
inflammation  must  be  named,  as  almost  invariably  present,  the 


312  DISEASES  OF  THE  THROAT  AND  NOSE. 


darthous  influence,  locally  manifested ;  but  occasionally  primary 
perichondritis  of  the  larynx  may  be  exhibited  as  a  form  of  senile 
phthisis.    The  following  is  an  instance  : 

Mr.  G.  B.,  aged  53,  residing  at  Newcastle,  consulted  me  in  September,  1878,  by  re- 
commendation of  Dr.  Macaulay.  He  stated  that  he  had  suffered  for  five  years  from 
hoarseness,  the  cause  of  which  he  could  not  assign.  This  symptom  had  been  unaccom- 
panied with  pain.  Two  months  previously  he  had  taken  a  severe  cold  in  the  head,  which 
appeared  to  travel  down  to  the  throat ;  the  voice  became  much  worse,  and  a  day  or  two 
later,  on  walking  to  his  office,  half  a  mile  from  his  home,  he  noticed  that  his  breathing 
was  short.  Though  for  some  weeks  he  had  experienced  slight  catching  in  his  breath 
before  sleep,  it  was  only  ten  days  prior  to  his  visit  to  me  that  he  had  his  first  serious 
attack  of  dyspnoea,  which  awoke  him  from  sleep  at  night. 

The  attacks  were  stridulous,  and  his  respiration  in  sleep  was  generally  very  noisy. 
The  patient  had  enjoyed  fairly  good  health,  and  as  a  superintendent  of  railway  traffic, 
had  travelled  a  good  deal.    During  his  journeys  he  had  been  accustomed  to  converse  on 
business,  and  had  often  felt  his  voice  tired.    He  had  never  had  syphilis,  and  was  an 
abstainer  from  alcohol  and  tobacco. 

His  family  history  was  bad  :  his  father,  who  had  been  asthmatic  for  many  years,  had 
died  at  65  ;  his  mother  of  phthisis  at  59,  and  two  brothers  and  a  sister  of  the  same 
disease.    One  married  sister,  aged  50,  was  living,  and  in  good  health. 

Examining  the  patient  I  found  his  T/oue  almost  suppressed,  but  occasionally  giving  0 
high-pitched  hoarse  note.  Respiration  was  continuously  embarrassed  and  stridulous, 
with  spasm  on  the  least  exertion.  It  was  always  worse  at  night.  Cough  irritable,  dry, 
and  unproductive.  Expectoration  scanty  and  glairy.  Paiti  only  for  the  last  two  days, 
radiating  from  larynx  to  the  ear.    Slight  tenderness  on  pressure  over  the  right  side  of 

the  larynx,  at  the  situation  of  the  thyroid  cartilage, 
and  especially  over  the  cricoid.  The  soft  tissues  of 
this  region  were  thickened. 

Examining  the  larynx  the  left  vocal  cord  was 
obscured  except  at  quite  its  posterior  part,  on  account 
of  inflammatory  swelling  of  the  corresponding  ven- 
tricular band.  The  right  vocal  cord  was  some- 
what congested  at  the  posterior  part,  and  the  mucous 
membrane  of  the  under  surface  along  its  whole  length 
greatly  infiltrated  as  with  oedema,  the  swollen  tissue 

Fig    CXXVI  Primary  Peri-  ^^^"S  P^"^*^  ^'^^  translucent.    The  lefL  vocal  cord  was 

CHONDRITIS  OF  Larynx.  quite  fixed,  and  there  was  but  little  movement  of  the 
right.  On  auscultation  of  the  lungs  a  very  good  per- 
cussion-note was  obtained  generally,  though  but  little  air  was  entering.  There  was  no 
evidence  of  aneurism,  of  enlarged  bronchial  glands,  or  other  disease,  and  the  diagnosis 
was  that  of  laryngeal  perichondritis,  probably  involving  all  the  cartilages,  and  especially 
the  cricoid. 

After  consultation  with  Mr.  Nunn,  tracheotomy  was  performed  with  considerable  relief 
to  the  breathing ;  but  the  patient's  health  was  never  regained,  and  Dr.  Macaulay  in- 
formed me  of  his  death  at  home  eighteen  months  later  of  gradual  decline.  His  lungs 
were  not  affiscted,  nor  wns  there  any  actual  evidence  of  abscess  in  the  region  of  the 
larynx  ;  but  the  pain  and  swelling  continued,  and  even  increased. 

Fibroid  degeneration,  which  is  rare,  is  probably  due  to  strumous 
causes. 

The  case  to  which  I  have  alluded  occurred  to  me  in  July,  1875,  and  came  under  my 
notice  in  consultation  with  Dr.  Gilbart  Smith.  The  patient,  who  was  a  slight  delicate 
girl  of  15  years  of  age,  complained  of  severe  difficulty  of  breathing,  which  had  existed 
for  three  months,  with  loud  stridor,  both  inspiratory  and  expiratory. 


INFLAMMATION  OF  PERICHONDRIUM  OF  LARYNX. 


313 


Tracheotomy  was  advised,  but  death  took  place  suddenly  and  quietly  on  the  day 
appointed  for  its  performance.  Autopsy  showed  oedema  of  the  larynx  with  ulceration  of 
the  right  cord,  involving  both  the  right  arytenoid  and  the  cricoid  cartilages,  which  as  well 
as  the  thyroid  were  unusually  soft  on  section.  The  right  bronchus,  the  right  pneuinogas- 
tric  and  recurrent  nerves  were  embedded  in  a  mass  of  hypertrophied  gland  tissue.  The 
lungs  and  heart  were  healthy,  and  the  case  was  considered  by  us  as  one  of  scrofulous 
perichondritis  of  the  larynx.  The  Morbid  Growth  Committee  of  the  Pathological  Society 
confirmed  our  opinion,  and  reported  that  there  was  no  evidence  of  either  tubercle  or 
syphilis. 

Traumatic  perichondritis  is  by  no  means  so  rare  as  is 
generally  supposed,  and  is  not  a  very  infrequent  result  of  intra- 
laryngeal  operations  for  the  removal  of  growths,  or  as  the  result  of 
wounds  by  knife,  sword,  or  gunshot.  *Von  Ziemssen  has  also 
alluded,  as  a  by  no  means  rare  cause  of  cricoid  perichondritis,  to 
'  the  frequent  introduction  of  the  oesophageal  sound  in  persons 
whose  cricoid  bone  is  ossified.'  Traumatic  disease  is  generally 
■confined  to  this  cartilage  and  to  the  arytenoids ;  the  thyroid  is 
less  liable  to  traumatism,  but  equally  so  to  the  other  degenerative 
processes 

I  have  never  seen  primary  perichondritis  of  the  epiglottis, 
though  such  a  disease  has  been  described :  it  must  in  any  case 
be  extremely  rare.  Spicer  has  mentioned  such  a  case  as  occurring 
in  a  boy  aged  10.  In  Fig.  78,  Plate  VIII.,  is  delineated  what 
was  beheved  to  be  gouty  deposit  in,  or  calcareous  degeneration 
of,  a  portion  of  the  epiglottis,  and  there  were  symptoms  of  gouty 
perichondritis  around  the  right  crico-arytenoid  articulation.  The 
patient  was,  however,  only  seen  twice,  and  the  after-history  could 
not  be  ascertained.  Acute  perichondritis  of  the  larynx  is  rarely 
primary,  and,  as  in  the  cases  just  detailed,  usually  occurs  in  persons 
of  advanced  life.  The  following  is,  however,  an  instance  of  this 
disease  in  a  child,  and  on  account  of  its  interest  is  narrated  at 
length : 

The  case  is  that  of  F.  B.,  set.  12,  to  which  brief  allusion  was  made  at  page  283, 
when  considering  acute  cedema  of  the  larynx.  The  boy  had  gone  to  sleep  in  a  hayfield 
one  day  early  in  July,  after  having  become  hot  and  tired  with  labour.  On  awaking  he 
felt  pain  and  stiffness  in  the  neck.  The  next  morning  his  mother  roused  him  from  sleep 
in  the  early  morning  because  of  the  'noise  he  was  making  in  his  breathing.'  He  felt 
intense  ear-ache  first  in  the  left  ear  for  three  weeks,  and  then  it  went  to  the  right  ear, 
lasting  on  that  side  fourteen  days.  On  the  first  morning  he  could  not  speak  when 
awoke,  but  the  next  day  could  do  so  hoarsely.  After  that  his  voice  became  gradually 
reduced  to  a  whisper.  It  had  been  quite  lost  for  six  weeks.  The  history  given  by  Mr. 
Evershed,  of  Arundel,  who  brought  him  to  me  on  September  15th,  1886,  evidently  pointed 
to  acute  inflammation  of  the  whole  tissues  of  the  larynx  and  of  the  neck.  He  was  im- 
mediately taken  into  the  Central  Throat  and  Ear  Hospital.  His  condition  v/as  as  follows  : 
Voice  quite  extinct.  Coug/i,  none.  Respiration  embarrassed  on  exertion,  noisy  in 
sleep.  Deglutition  painful.  Temperature  and  pulse  normal.  Lungs  resonant  in  front, 
rather  dull  at  upper  posterior  part ;  breath-sounds  faint,  harsh,  and  dry  ;  expiration 
prolonged.    Appetite  good.    Weight,  5  st.  8  lb.    The  neck  was  no  longer  swollen, 


314 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Fig.  CXXVII. 


Fig. 


CXXVIII. 


but  there  was  distinct  tenderness  on  even  gentle  manipulation  of  the  larnyx  externally, 
and  the  pomtuii  was  somewhat  thickened.  With  the  laryngoscope  there  was  seen  to 
be  considerable  oedema  of  both  ary-epiglottic  folds,  and  a  thickened  and  somewhat  granu- 
lated condition  of  the  anterior  two-thirds  of  the 
vocal  cords,  so  that  there  was  no  space  to  be 
observed  between  them  on  full  inspiration.  The 
cords  generally  were  inflamed,  and  the  right  cord, 
or  rather  its  corresponding  arytenoid  cartilage 
(Fig.  CXXVII.),  was  immobile. 

The  diagnosis  was  that  acute  oedema  and  peri- 
chondritis had  occurred  simultaneously,  and  that 
both  had  now  passed  into  the  subacute  stage. 

He  was  ordered  a  milk  diet,  a  Leiter  cold  coil 
to  be  worn  constantly ;  hypodermic  injections  of 
grain  of  pilocdrpine  were  made  on  the  i6th, 
17th,  and  i8th,and  of  J  grain  on  the  23rd,  without 
much  effect  on  the  local  condition.  He  had  no 
other  remedies  for  the  first  fortnight,  when  he  was 
ordered  iodide  of  iron  with  iodide  of  potassium, 
and  frequent  inhalations  of  the  vapour  of  benzoin 
(Form.  29).  The  granular  state  of  the  cords  de- 
creased ;  but  their  median  line  of  demarcation,  as 
well  as  the  difference  of  level  between  them  and 
the  ventricular  bands,  gradually  became  less  dis- 
tinct, and  on  October  14th  these  tissues  appeared 
to  have  become  quite  united  (Fig.  CXXVIII.) : 
there  was  a  small  rounded  prominence  at  the  most 
anterior  visible  portion  of  the  right  vocal  cord, 
which  was  still  impaired  in  mobility.  On  this 
day  I  first  introduced  Whistler's  cutting  dilator, 
and  repeated  its  use  on  the  17th,  and  twice  a  week 
till  November  4th,  when  the  glottic  space  was  seen 
to  be  much  larger  ;  but  a  well-defined  sessile  pro- 
jection was  now  observed  on  the  right  vocal  cord 
in  the  situation  of  the  before-mentioned  slight 
prominence.  The  larynx  was  still  further  opened 
with  the  dilator,  and  on  November  I5tli  the  pro- 
jection on  the  right  cord  was  seen  to  be  a  dis- 
tinct growth  (Fig.  CXXIX.).  A  wire  loop  and 
Voltolini's  sponge  were  now  employed,  and  after 
four  or  five  operations,  all  trace  of  the  growth 
was  gone  (Fig.  CXXX.).  After  that  Schroetter's 
No.  2  size  hollow  vulcanite  dilator  was  intro- 
duced every  other  day,  with  occasional  use  of  the 
cutting  dilator.  Return  of  the  voice  was  first 
observed  on  December  6th,  and  from  that  time 
improvement  was  progressive.  He  left  the  hos- 
pital for  a  holiday  at  home  on  December  22nd 
with  an  open  larynx  somewhat  hyperasmic ;  the 
cords  devoid  of  new  growth  and  both  acting  equally.  He  had  a  fairly  good,  though 
rough  voice,  and  complete  ease  of  all  respiratory  symptoms.  He  had  gained  12  lb.  in 
weight  during  his  slay  of  thirteen  weeks.  On  January  17th,  1887,  this  patient  returned 
with  voice  much  stronger,  and  the  larynx  generally  less  congested.  The  small  portion  of 
ihe  larynx  still  adherent  was  divided,  and  dilatation  continued  till  the  opening  was 
normal  in  area. 

It  is  probable  that  in  almost  all  perichondrial  inflammations 


Fig.  CXXIX. 


fJkif./fii. 

CXXX. 


Figs. 


CXXVIII., 
CXXIX.,  AND  CXXX.— Pri- 
MARY  Perichondritis. 
Various  Views  under 
Treatment. 


INFLAMMATION  OF  PERICHONDRIUM  OF  LARYNX.  315 


which  are  not  the  result  of  traumatism,  the  disease  commences  in 
the  neighbourhood  of  the  crico-arytenoid  joint.  In  many  cases 
the  dehcate  articulations  between  the  arytenoid  and  cricoid 
cartilages  become  the  seat  of  plastic  transudation,  and  even  after 
the  acute  stage  of  an  inflammation  has  passed  off  partial  or  com- 
plete immobility  of  the  vocal  cords  results.  "^Schroetter  reports 
eight  cases  of  stenosis  due  to  anchylosis  of  the  arytenoids  from 
perichondritis  following  typhus.  ^Lunning,  of  Zurich,  and  ^Ses- 
tier,  both  quoted  by  ^^De  Havilland  Hall,  have  found  it  frequently  in 
typhoid.  In  both  these  diseases  there  is,  of  course,  extreme  exhaus- 
tion, and  the  patient  is  lying  supine  many  weeks.  How  much, 
therefore,  of  the  perichondrial  changes  may  be  due  to  a  specific 
poison,  and  how  much  to  decubitus,  it  is  not  possible  to  determine. 
Another  form  of  this  kind  of  anchylosis  occurs  in  connection  with 
tuberculosis,  even  before  occurrence  of  ulceration ;  such  a  condition 
being  analogous  to  the  scrofulous  stiffening  of  the  larger  joints. 

I  have  seen  two  cases  which  I  believe  to  be  anchylosis  of  the 
crico-arytenoid  articulation  due  to  rheumatism. 

One  occurred  in  a  young  gentleman,  aged,  when  he  first  came  under  notice,  about 
12.  He  has  been  under  my  occasional  observation  ever  since,  and  is  now  about  23. 
I  lis  right  cord  is  quite  fixed,  and  his  voice  has  always  been  hoarse,  though  it  has  improved 
in  the  last  two  or  three  years. 

The  other  case  is  that  of  a  man  73  years  of  age,  at  present  attending  the  hospital,  in 
whom  it  is  impossible  to  otherwise  account  for  the  fixature  of  the  right  vocal  cord,  and  for 
a  persistent  hoarseness.  In  the  first  case  the  arthritic  diathesis  was  strongly  manifested 
in  the  father.  In  the  second,  the  patient  has  several  evidences  of  the  same  condition  ia 
the  joints  of  his  hands,  and  in  the  cartilages  of  the  ear  (1887). 

Other  chronic  forms  of  perichondritis,  not  leading  to  caries  or 
abscess,  are  those  associated  with  syphilis,  and  are  the  result  of 
organization  of  the  inflammatory  exudation. 

The  following  two  cases  are  recorded  as  ordinary  examples  of 
secondary  perichondritis,  the  first  in  connection  with  syphilis : 

F.  S.,  aged  39,  a  labourer,  was  admitted  into  the  hospital,  November  15,  1886.  He 
stated  that  he  had  suffered  from  primary  syphilis  nineteen  }ears  previous'y,  and  since  that 
lime  had  had  occasional  sore  throats.  Two  months 
Defore  application  'he  had  noticed  a  lump  in  the 
apple  of  the  throat.'  It  was  not  painful,  nor  did  it 
interfere  with  his  swallowing.  His  breath  was  short 
and  his  voice  hoarse. 

Ojz  external  exajjima/ion,  a  moderately  soft  semi- 
elastic  bi -lobular  swelling  about  the  size  of  a  hen's 
egg  was  observed  in  front  and  rather  to  the  left  of 
the  larynx ;  situated  on  a  lower  level  than  would 
be  the  case  had  it  been  an  enlarged  bursa  over 
the  hyoid  bone,  and  higher  than  the  situation  of  the 
thyroid  gland,  it  was  judged  to  be  a  gumma,  the 
diagnosis  being  confirmed  by  the  presence  of  a 
*  punched-out '  ulcer  at  the  upper  end  of  the  swelling, 
about  the  size  of  a  shilling,  and  a  quarter  of  an  inch 

in  depth ;  and  at  the  lower  and  left  part  a  highly  inflamed  spot  of  rather  smaller  area. 


Fig.  CXXXI.— Syphilitic  Peri- 
chondritis. 


3r6  DISEASES  OF  THE  THROAT  AND  NOSE. 

On  laryngoscopic  exauiination  the  left  arytenoid  cartilage  and  left  ary-epiglottic  fold  were 
seen  to  be  greatly  swollen,  and  the  left  vocal  cord  was  immovably  fixed  (Fig.  CXXXL). 

To  complete  the  history,  it  may  be  briefly  mentioned  that  the  gumma  over  the  larynx 
required  opening  in  a  few  days  ;  that  the  external  ulcer  healed  under  application  of  black 
wash,  and  that  the  general  condition  of  the  larynx  improved  under  a  course  of  twelve 
mercurial  inunctions  of  the  limbs  and  trunk.  A  gumma  then  developed  in  the  posterior 
middle  portion  of  the  right  lung,  which  was  accompanied  by  high  fever.  This  was 
reduced  by  local  inunction  and  salicylates.  Another  gumma  then  developed  in  the  soft 
palate  above  the  right  tonsil ;  this  suppurated  and  required  to  be  opened  ;  concurrently 
he  suffered  from  bi-lateral  tonsillitis.  He  made  in  the  end  a  good  recovery,  but  though 
both  the  external  and  internal  laryngeal  swelling  became  much  reduced,  the  vocal  cord 
remained  fixed.    The  patient  was  unable  to  take  iodides  in  any  form. 

The  next  case  is  one  of  chondro-sarcoma,  which  recently 
occurred  in  the  cHnique  of  my  colleague,  Dundas  Grant,  who 
kindly  permits  me  to  quote  it.  The  disease  probably  commenced 
in  the  region  of  the  crico-arytenoid  articulation,  but  later  involved 
both  the  right  side  of  the  thyroid  and  also  of  the  cricoid. 

C.  W.,  aged  43,  a  tramcar-driver,  applied  at  the  hospital  on  August  10, 1886,  on  account 
of  pain  in  swallowing,  which  had  existed  for  only  a  week  or  two,  but  had  each  day 

become  intensified.  Neither  voice  nor  res- 
piration were  seriously  distressed  when  first 
seen.  On  laryngoscopic  examination  the 
appearance  in  the  accompanying  drawing  was 
presented.  The  infiltration  of  the  tissues 
covering  the  right  arytenoid  cartilage  was  very 
considerable  and  semi-solid  in  character,  and, 
as  will  be  seen,  the  demarcation  of  the 
eminences  of  Wrisberg  and  Santorini  were  by 
no  means  lost,  as  is  the  case  in  simple  serous 
oedema.  The  right  cord  was  obscured  by  the 
swelling  of  the  ventricular  band,  and  the  whole 
Fig.  CXXXII.— Laryngeal  Chon-  right  side  of  the  larynx  was  fixed. 
dro-Sarcoma  and  Perichondritis.       The  diagnosis  from  syphilitic  or  other  form 

of  perichondritis  was  clearly  established,  not 
only  by  a  general  malignant  cachexia  of  the  patient,  markedly  present  in  this  case,  but  also 
by  the  almost  stony  hardness  of  an  external  swelling  in  the  right  superior  cervical  region. 

The  temperature  never  ranged  above  99°,  and  was  frequently  below  normal.  Once  or 
twice  it  fell  to  97 "5°.  The  case  progressed  very  rapidly,  and  the  patient  died  away  from 
the  hospital  on  December  20,  about  four  months  from  the  date  of  his  first  symptoms. 
Unfortunately  no  autopsy  was  obtained. 

Symptoms. — It  is  hardly  possible  to  follow  the  order  observed 
throughout  this  work  in  the  consideration  of  this  disease,  since  in 
its  subacute  and  chronic  form  it  is  so  insidious  that  both 
functional  and  physical  signs  undergo  very  gradual  progressive 
changes.  The  first  symptom  is  generally  one  of  localized  pain, 
often  ascribed  to  neuralgia ;  but  careful  external  examination  will 
frequently  detect  a  slight  unevenness  at  the  painful  spot,  and  the 
part  will  be  distinctly  tender  to  touch  ;  sometimes  there  is  to  be 
felt  by  the  surgeon  c  crepitation  or  grating  similar  to  what  one 
discovers  on  movement  of  an  arthritic  knee-joint ;  concurrently, 
or  soon  afterwards,  the  patient  will  complain  of  more  or  less 


INFLAMMATION  OF  PERICHONDRIUM  OF  LARYNX.  317 


difficulty  in  deglutition,  of  a  feeling  of  stiffness  in  the  larynx,  and 
of  a  *  catch '  in  the  respiration,  which  will  also  be  short  on  the 
least  exertion.  This  question  of  dyspnoea  is  one  of  importance,  as 
it  will  greatly  influence  indications  for  treatment.  It  may  be  due 
to  '  oedema,  immobility,  and  median  position  of  one  or  both  vocal 
cords,  abscess,  impaction  of  the  necrosed  cartilage  in  the  glottis, 
collapse  of  the  cartilaginous  wall  of  the  larynx,  and  finally  in  the 
healing  of  the  ulceration ;  this  is  almost  entirely  confined  to 
syphilitic  cases '  (Hall).  Concurrently  with  the  difficulty  of 
breathing,  the  voice  will  be  noticed  to  be  hoarse,  possibly  rather 
high-pitched,  and  cough  will  become  stridulous,  and  somewhat 
paroxysmal.  With  all  this  the  patient  will  not  perceptibly 
emaciate,  unless  the  disease  be  associated  with  cancer  or  tubercle, 
or  at  least  loss  of  flesh  will  be  more  gradual  than  is  usual  in  either 
of  these  diseases ;  he  will  continue  to  take  exercise,  or  even  to 
follow  his  vocation ;  and  the  morbid  condition  may  not  vary,  or 
the  symptoms  may  only  become  slightly  aggravated,  for  many 
months. 

On  laryngoscopic  examination  at  this  stage,  physical  changes 
will  be  by  no  means  well  marked.  In  many  cases,  beyond  capil- 
lary injection  of  the  mucous  membrane,  there  will  be  little  or  no 
indication  to  the  eye  of  the  serious  changes  that  may  be  taking 
place  in  the  deeper  structures.  ^^Macdonald  lays  stress  on  what 
he  terms  a  *  crowding  of  the  laryngeal  structures  towards  the 
middle  line  by  surrounding  perichondrial  swelling,'  a  phenomenon 
by  no  means  constant,  and  according  to  my  experience  most  fre- 
quently manifested  in  syphilitic  cases.  When  an  abscess  forms,  it  is 
very  difficult  to  distinguish  whether  it  arises  as  the  result  of  Sl 
submucous  inflammation  or  of  a  perichondritis.  When  the  disease 
affects  the  thyroid  cartilage  there  will  be  more  or  less  tumefaction 
*  (sometimes  almost  inappreciable  in  amount),  with  some  hyperaemia 
'  of  the  ventricular  band  of  the  affected  side.  If  the  arytenoid  car- 
'  tilage  or  the  crico-arytenoid  articulation  be  the  part  attacked,  the 
vocal  cord  will  be  inflamed  with  possibly  sub-glottic  swelling,  and 
especially  will  be  observed  more  or  less  impairment  in  the  action 
of  the  cord  of  the  affected  side  (Fig.  77,  Plate  VIII.).  The  ary- 
tenoids may  be  attacked  singly  or  together,  and  by  their  enlarge- 
ment encroach  upon  the  lumen  of  the  glottis.  This  also  will  be 
evident  in  the  mirror.  If  the  cricoid  cartilage  be  diseased,  the 
tumefaction,  being  situated  beneath  the  vocal  cords,  may  be  at 
first  unnoticed  (Fig.  79,  Plate  VIII.),  or  under  certain  conditions 
obscured.  This  is  especially  the  case  if  one  side  of  the  cartilage 
be  first  attacked  (a  very  rare  circumstance),  instead  of,  as  is  usual. 


318 


DISEASES  OF  THE  THROAT  AND  NOSE. 


one  of  its  plates,  or  if  the  disease  commence  in  the  perichondria! 
layer  adjoining  the  oesophageal  wall,  which  is  also  rare. 

The  following  case,  believed  to  be  of  this  variety,  and  a 
secondary  result  of  typhoid  fever,  is  that  of 

J.  H.  McD.,  aged  28,  an  engineer,  who  was  admitted  into  hospital  on  June  4,  1885,  stating 
that  he  had  only  risen  {rem  his  bed  two  or  three  weeks  previously  after  a  protracted 
attack  of  typhoid  fever.  For  the  last  fortnight  he  had  experienced  difficulty  of  breathing, 
with  gradual  increase,  so  that  now  he  had  frequent  attacks  of  choking,  with  cough  and 
expectoration.  He  complained  of  no  pain.  Laryngoscopy  showed  a  small  erosion  of  the 
left  angle  of  the  epiglottis,  and  general  laryngeal  oedema,  producing  considerable  stenosis. 
There  was  a  suspicion  of  syphilis,  though  no  acknowledged  history,  for  there  was  an 
unindurated  scar  on  the  dorsum  of  the  penis,  and  a  shot-like  string  of  glands  to  be  felt  in 
each  groin.  His  voice  was  high-pitched  and  polyphonic  ;  'his  respiration  noisy  and 
stridulous  on  inspiration.  There  was  but  little  air  entering  his  lungs,  which  were  free 
from  disease.  He  suffered  from  profuse  nocturnal  sweatings.  He  was  ordered  full  doses 
of  iodide  of  potassium  ;  and  a  meeting  was  arranged  for  the  purpose  of  performing 
tracheotomy,  but  the  patient  died  thirty  hours  after  admission.  On  autopsy,  the  lungs 
were  collapsed,  especially  the  right,  and  there  was  some  muco-pus  in  the  larger  bronchi. 
There  was  no  consolidation  nor  tubercle.  Heart  was  healthy.  There  were  three  or  four 
scars  of  recent  ulceration  near  the  ilio-ccecal  valve.  On  examining  the  larynx,  the  mucous 
membrane  was  observed  to  be  generally  puckered  and  sodden.  Pus  was  seen  to  issue  from 
a  small  fistulous  opening  behind  the  juncture  of  the  cricoid  and  thyroid  cartilages  rather  to 
the  left  side,  and  in  front  of  the  oesophagus.  On  dividing  the  larynx  from  behind  through 
the  middle  line,  an  irregular  cavity,  which  extended  laterally  on  both  sides,  was  opened ; 
it  contained  pus,  and  the  left  posterior  plate  of  the  cricoid  cartilage  was  separated  from 
the  perichondrium,  and  was  rough  and  necrosed. 

It  is  equally  clear  that,  under  certain  conditions  of  the  cricoid 
cartilage,  the  action  of  the  vocal  cords  may  not  be  greatly  impeded, 
and  occurring,  as  the  disease  does,  in  old  people,  slight  muscular 
palsy  may  not  give  rise  to  any  apprehension.  Hall,  in  the  article 
already  referred  to,  mentions  that  ^^Fraenkel  explains  the  immo- 
bility and  median  position  of  one  or  both  vocal  cords  as  a  mecha- 
nical result  of  the  loss  of  attachment  of  the  postici  to  the  cricoid 
cartilage,  and  not  as  due  to  a  paralysis  of  the  nerves.  If  only  a 
small  amount  of  damage  be  done  to  the  crico-arytenoid  joint, 
when  recovery  occurs  a  mistake  may  be  very  readily  made  in 
regarding  the  fixed  position  of  the  cord  as  the  result  of  para- 
lysis of  the  crico-arytcnoideus  posticus.  In  the  case  of  any 
patient  coming  with  symptoms  such  as  have  been  sketched,  the 
greatest  attention  must  be  given  to  commemorative  signs  as  well 
as  to  laryngoscopic  appearances,  for  it  very  frequently  happens  that 
only  by  careful  differentiation  of  points  in  the  mdividual  and  family 
history  can  an  exact  diagnosis  of  the  nature  of  the  perichondrial 
disease  be  ascertained.  There  is  very  frequently  a  distinct  personal 
experience  of  gouty  attacks  in  other  portions  of  the  body,  with 
evidence  of  deposit  in  one  or  more  joints  of  the  extremities. 

At  the  time  of  writing  my  last  edition,  I  had  a  case  under  my  care  in  which  slight 
dysphagia  was  the  prominent  symptom.  The  patient  was  a  lady  aged  62,  and  the 
opinion  had  been  given  that  she  was  the  subject  of  malignant  stricture  :  she  had  recently 


INFLAMMATION  OF  PERICHONDRIUM  OF  LARYNX.  319 


had  an  attack  of  gouty  iritis  ;  she  had  chalky  deposit  in  the  distal  phalangeal  articulation 
of  each  Itttle  finger  and  in  the  auricular  cartilages,  and  local  manifestations  in  the  larynx 
were  gradually  giving  evidence  of  undoubted  perichondrial  change  (Fig.  79,  Plate  VIII.). 
The  later  history  confirmed  this  diagnosis. 

Prognosis,  Course,  and  Termination. — Perichondrial  in- 
flammation and  degeneration  of  a  laryngeal  cartilage  must  always 
be  viewed  with  real  alarm  as  to  the  result  to  life.  Cases  (non- 
specific) have  occurred,  however,  in  which  the  arytenoid  cartilages 
have  been  discharged  and  the  patient  has  recovered  ;  and  such  a 
result  has  even  been  reported  after  extrusion  of  the  plate  of  the 
cricoid.  Chronic  syphilitic  perichondritis  is  not  always  fatal,  though 
but  too  often  an  acute  relapse  occurs  which  calls  for  tracheotomy. 
Even  when  tracheotomy  is  not  rendered  necessary,  there  is  more 
or  less  injury  to  both  the  vocal  and  the  respiratory  mechanism, 
from  anchylosis. 

The  comparatively  passive  early  stage  of  all  forms  of  subacute 
perichondritis  passes  gradually  into  one  of  greater  gravity  if  caries 
occurs ;  the  urgency  being  caused  by  formation  of  an  encysted 
abscess  around  the  diseased  cartilage,  which  in  its  growth  greatly 
aggravates  all  the  symptoms,  and  may  lead  to  extreme  stenosis  of 
either  gullet  or  larynx.  This  abscess  may  burst,  and  portions  of 
necrosed  cartilage  be  discharged  from  it. 

If  the  abscess  burst  during  life,  it  may  open  into  the  oesophagus, 
or  into  the  larynx,  leading — it  may  be — to  a  fistulous  communica- 
tion between  these  two  passages ;  or,  if  the  disease  be  anterior, 
there  may  be  an  external  fistulous  passage  complicated  by  sub- 
cutaneous emphysema.  Death  usually  terminates  by  exhaustion, 
from  the  suppurative  discharge  and  consequent  irritative  fever, 
or  it  may  take  place  even  before  the  abscess  is  opened. 

Treatment. — Beyond  relief  of  the  inflammatory  stage  by  the 
application  of  continuous  cold,  sedative  inhalations,  etc.,  not  much 
can  be  effected,  because  there  is  probably  no  measure  which  can 
prevent  or  arrest  perichondrial  caries  or  other  changes  when  once 
established,  and  all  the  surgeon  can  do  is  by  every  care  to  perfect 
his  diagnosis,  and  to  watch  attentively  for  signs  of  suppuration. 
He  should  then,  if  possible,  open  the  abscess,  having  first,  unless 
it  can  be  reached  from  without,  performed  tracheotomy.  On  no 
account  should  the  idea  of  laryngotomy  or  laryngo-tracheotomy, 
advised  by  some  authors,  be  entertained  ;  indeed,  it  is  very  doubtful 
whether  this  operation  should  ever  be  performed  except  for  quite 
temporary  purposes.  In  all  cases  in  which  a  tube  has  to  be  worn 
for  any  length  of  time,  the  further  it  is  from  the  laryngeal  carti- 
lages, the  greater  the  chance  of  the  patient  living  more  than 


320  DISEASES  OF  THE  THROAT  AND  NOSE, 


twelve  or  eighteen  months  after  the  operation,  which  is  probably 
about  the  average  extension  of  life  usually  gained  by  this  means 
when  performed  for  chronic  laryngeal  disease. 

Where  there  is  stricture  of  the  oesophagus,  feeding  by  the 
oesophageal  tube  may  be  employed ;  the  irritation,  however,  of 
such  an  instrument  is  but  too  apt  to  increase  the  evil,  and  this 
method  of  nourishment  should  be  reserved  for  those  cases  in 
which  there  is  fistulous  communication  between  the  larynx  and 
oesophagus. 

There  are  few  cases  in  which  raw-egg  feeding  could  not  be 
pursued,  to  which  may  be  superadded  one  or  two  daily  nutrient 
enemata  per  rectum. 

REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

I 

Lennox  Browne. 

2 

Von  Ziemssen. 

311 

3 

Stoerk. 

311 

4 

Gerhardt. 

5 

SCANES  SpICER. 

6 

Von  Ziemssen. 

7 

Schroetter. 

315 

8 

LUNNING. 

315 

9 

Sestier. 

315 

10 

De  Havilland  Hall. 

II 

Macdonald. 

12 

Fraenkel. 

title  of  work  referred  to. 


Pathological  Transactions,  vol.  xxvii. 
/  Handlmch   der  Specielkn  Pathologie^ 
\     vol.  iv.,  p.  333. 

/  Klinik  der  Kraiikheiten  des  Kehlkopfes, 
\     Stuttgardt,  1880. 
Archives  of  Laryngology ^  vol.  i.,  p.  19. 

New  York,  1881. 
British   Medical  Journal.    Sept.  14, 
1889. 

Cyclopcsdia    of    Medicine^    vol.  vii. 
London,  1876-77. 
j  Beitrag  zur  Behandlung  d.  Larynx- 
(     stejiose.    Vienna,  1876. 
Centralblatty  fiir  Laryngol,  vol.  i.,  p. 
73- 

\  Transactions  of  Pathological  Society, 
(     vol.  xxxi.,  p.  37. 

(  British  Medical  Journal.  Sept.  14, 
j  1889. 

British  Medical  fournal.    Sept.  14, 
1889. 

Berlin  Klin.  Wochenschr.,  1887,  No.  24, 
p.  439- 


\ 


CHAPTER  XVL 

EXUDATIVE  OR  MEMBRANOUS  INFLAMMATION  OF  THE 

LARYNX. 

IDIOPATHIC  AND  TRAUMATIC. 

Synonyms.  —  Membranous  laryngitis;  Croupous  laryngitis; 
Cynanchea  trachealis  ;  Croup. 

Although  hitherto  I  have  carefully  avoided  the  temptation  to 
indulge  in  dogmatic  definitions  of  each  separate  disease  as  it  came 
under  consideration,  it  is  necessary  to  say  at  the  beginning  of  this 
chapter  that  by  the  term  croup  I  mean  a  pseudo-membranous 
inflammation  of  the  air-passages  of  an  essentially  non-infectious 
and  non-contagious  nature,  v^hich  exhibits  local  rather  than  con- 
stitutional symptoms.  The  local  signs  are,  to  some  extent, 
identical  with  the  surface  manifestations  of  diphtheria.  Their 
effect  on  the  constitutional  state  is  altogether  distinct  and 
different. 

It  may  be  considered  heterodox  in  the  present  day  to  express 
belief  in  the  existence  of  a  non-specific  exudative  inflammation 
of  the  larynx ;  the  opinion  is  nevertheless  still  held — and,  as  I 
venture  to  think,  correctly — by  many  able  practitioners.  Few- 
authors  of  systematic  treatises  on  medicine  omit  its  considera- 
tion;  and  ^Aitken  may  be  taken  to  represent  the  sentiment  of 
many  doctors  of  great  practical  experience,  but  who  may  never 
have  written  a  line  on  the  subject,  when  he  says  that  *  anyone 
who  has  seen  much  of  croup  in  children  can  have  no  difficulty 
in  recognising  it  as  a  disease  very  different  from  diphtheria  in 
its  attack,  its  course,  and  its  results.*  Aitken  is  supported  in 
this  view  by  such  eminent  authorities  of  the  older  school  of 
modern  authors  as  ^Watson  (earlier  editions),  ^Niemeyer, 
*  Burrows,  and  ^Tanner,  and  by  others  more  recent  but  equally 
distinguished — to  wit,  ^Broadbent,  ^Roberts,  ^Wilks,  and  ^Hilton 
Fagge.  The  last-named  author  draws  attention  to  the  circum- 
stance  that  both   Home  and  ^^Cheyne,  two  of  the  earhest  writers  on  . 

21 


322 


DISEASES  OF  THE  THROAT  AND  NOSE, 


croup,  '  were  perfectly  acquainted  with  the  fact  that  the  disease 
which  they  described  was  hable  to  be  confounded  with  one  which 
affected  the  larynx  secondarily,  having  its  original  seat  in  the 
fauces  ;'  and  he  goes  on  to  say:  *  Probably  each  of  these  observers 
had  better  opportunities  of  studying  the  relations  of  the  two 
diseases  than  any  London  physician  in  the  present  day,  and  I 
think  it  is  worthy  of  notice  that  if  they  should  prove  to  have  been 
wrong  in  regarding  them  as  distinct,  the  progress  of  medical 
science  will,  in  this  instance,  lead  to  a  result  directly  opposite  to 
that  which  it  is  bringing  about  in  all  other  cases ;  for,  in  regard  to 
every  other  group  of  diseases,  the  more  our  knowledge  advances 
the  more  are  distinctions  and  divisions  multiplied.'  For  myself, 
I  can  say  that  the  memory  will  never  be  effaced  of  the  caser  I 
saw  of  true  croup  when  a  pupil  in  the  country  between  the  years 
1857  i859>  3-  time  when  diphtheria  was  very  rife,  and  when 
medical  attention  was  being  very  urgently  drawn  to  it  and  to  the 
distinctions  between  the  two  diseases. 

Leaving,  for  the  moment,  consideration  of  so-called  idiopathic 
croup,  we  would  draw  attention  to  the  fact  that  false  membranes 
of  essentially  the  same  macroscopic  and  microscopic  character  as 
those  of  septic  (diphtheritic)  origin  can  be  produced  on  the 
mucous  lining  of  the  buccal  cavity  and  air-passages  by  every  kind 
of  traumatism,  as,  for  example,  irritant  poisons,  solid,  fluid  or 
gaseous,  scalding  water,  scorching  heat,  chemical  or  galvano- 
caustics,  or  even  strong  eau  de  Cologne.  ^-Oertel  performed  the 
experiment  of  dropping  a  few  mimins  of  liquor  ammoniae  into  the 
trachea  of  seventeen  animals,  and  succeeded,  in  every  instance,  in 
generating  an  artificial  croup.  Between  these  two  extreme  classes 
of  exudative  or  membranous  laryngitis — the  one  purely  local  in 
origin  and  effect,  the  second  entirely  constitutional — we  have  two 
other  varieties  :  the  first,  which  we  call  crotcp,  a  simple  exudative 
inflammation,  varying  in  the  extent  and  consistence  of  the  exuda- 
tion according  to  the  intensity  of  the  factor,  which  is  principally 
atmospheric ;  the  second,  a  form  of  inflammation  which  may  be 
mucous,  submucous,  or  membranous,  according  to  age  and  to  the 
intensity  of  the  factor,  which  last  is  not  so  septic  as  is  that  of  diph- 
theria, so  purely  local  as  in  the  case  of  traumatism,  nor  dependent 
so  entirely  on  hygienic  conditions  as  in  croup.  We  allude  to  the 
mflammations  of  the  larynx  which  take  place  as  secondary  results 
of  some  of  the  exanthemata,  of  typhus  and  typhoid,  and  of 
erysipelas.  All  of  these  three  classes  of  membranous  inflamma- 
tions are  mainl};-  distinguished  from  diphtheria  by  the  conspicuous 
absence  of  certain  grave  constitutional  symptoms  and  sequelae. 


IDIOPATHIC  CROUP. 


323 


These  and  other  questions  of  differential  diagnosis  will  pre- 
ferably be  discussed  in  our  remarks  on  diphtheria,  and  we  will  at 
once  proceed  to  the  consideration  of  that  affection  which  is 
ordinarily  and  tersely  designated  as  tme  croup,  or,  since  that  term 
is  held  by  many  to  be  misleading  and  incomplete,  of  simple  exuda- 
tive laryngitis.  We  prefer  the  term  exudative  to  membranous, 
for,  although  in  an  extreme  case  of  croup,  the  formation  of  false 
membrane  constitutes  one  of  its  most  serious  manifestations, 
there  are  other  varieties  of  laryngitis  in  children  less  severe  in 
their  objective  evidences,  but  presenting  exactly  the  same 
functional  symptoms  and  hardly  less  perilous  to  existence.  Thus 
almost  all  authors  agree  with  Aitken  to  have  two  forms  of  croup — 
the  mvicous  and  the  fibrinous  ;  and  Cohen  goes  so  far  as  to  sub- 
divide the  disease  into  three  varieties — the  catarrhal,  membranous, 
and  suppurative.  These  subdivisions  are  of  importance,  in  so  far 
as  they  emphasize  the  view  that  the  disease  is  one  of  simple  and 
not  specific  character.  In  a  measure  also  they  may  be  said  to  in- 
fluence prognosis.  Fagge  considers  two  kinds  of  croup,  one  w^hich 
he  somewhat  unfortunately  denominates  the  spurious — without 
exudation — but  which  he  carefulty  distinguishes  from  lajyngismus 
stridulus;  the  second,  membranous.  He  appears  to  consider  the 
first  merely  as  a  milder  form  of  the  second,  and  differentiated 
principally  by  the  absence  of  exudation.  His  opinion  on  this 
point,  therefore,  is  in  accordance  with  that  of  Aitken. 

Etiology. — The  disease  is  essentially  one  of  childhood,  and  is 
seldom  observed  before  the  first  year  of  life,  or  after  the  period  of 
first  dentition.  We  have  repeatedly  stated  a  belief  that  anatomical 
differences  in  the  structure  of  the  mucous  membrane  account 
mainly  for  the  greater  frequency  of  exudative,  and  for  the  rarity 
of  submucous,  inflammations  in  children  as  compared  with  adults 
'(see  pages  275  and  298).  Holding  this  view,  we  need  say  no  more 
.as  to  the  causes  of  membranous  laryngitis  than  that  they  are  for 
the  most  part  the  same  as  those  of  acute  laryngeal  oedema. 

We  find,  for  example,  that  exposure  to  keen  northerly  or  north- 
'easterly  winds,  and  a  surface-chill,  are  pretty  generally  assigned 
as  the  origin  of  croup.  There  is  undoubtedly  also  a  constitutional 
state,  by  no  means  accurately  determined,  which  appears  to  pre- 
dispose certain  families,  and  certain  members  of  a  family,  to  this 
form  of  inflammation.  Children  liable  to  croup  for  the  most  part 
suffer  during  dentition,  and  have  a  tendency  to  rachitis  and  intes- 
tinal irritation;  they  are  also  subject  to  influenza,  to  bronchitis, 
and  to  pneumonia,  as  well  as  to  catarrhal  and  inflammatory  affec- 
tions of  the  respiratory  organs  generally,  and  they  are  readily 


3^4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


susceptible  to  be  attacked  during  epidemics,  such  as  measles  or 
whooping-cough.  Seeing  how  strong  a  predisponent  to  bronchitis 
is  mouth-breathing,  it  is  quite  Hkely  that  the  presence  of  adenoid 
growths  in  the  vault  of  the  pharynx  which  obstruct  free  nasal  re- 
spiration, would,  if  searched  for,  be  found  in  many  victims  to  croup. 
Not  only  is  the  mucous  membrane  very  sensitive,  but  there  is  an 
unusually  delicate  character  of  the  skin,  the  epidermis  of  which  is 
abnormally  thin,  so  that  the  superficial  veins  of  the  face,  trunks 
and  hmbs  are  much  plainer  observed  than  in  others  not  so  con^ 
stituted.  Boys  are  said  to  suffer  more  than  girls;  but  the  accuracy 
of  the  statement  is  questionable.  There  is,  however,  no  such 
doubt  in  my  mind  as  to  the  influence  of  heredity.  The  asserti^ 
that  robust  children  are  more  liable  to  croup  than  delicate 
applies  with  more  accuracy  to  the  false  or  spasmodic  form  than 
to  the  inflammatory.  ,  Niemeyer  has  found  that  children  liable  to 
be  attacked  have  a  tendency  to  moist  eruptions,  or  to  acute  hydro- 
cephalus ;  and  *  it  would  appear  that  croup  not  unfrequently 
begins  very  soon  after  the  disappearance  of  a  moist  eruption  on: 
the  head  or  face.' 

Croup  is  said  to  be  epidemic  or  endemic ;  but  such  a  circum- 
stance is  doubtful,  and,  since  all  evidence  goes  to  show  that  croup 
is  not  contagious,  an  explanation  of  the  occurrence  of  more  than 
one  case  in  a  house  or  a  district  is  always  to  be  afforded  by  the 
existence  of  simultaneous  climatic,  atmospheric,  and  constitutional 
causes.  The  affection  is  more  common  in  the  country  than  in 
towns,  which  fact  may  be  probably  explained  by  the  circumstance 
that  atmospheric  and  other  climatic  causes  are  less  neutralized 
in  the  distantly  separated  dwellings  of  rural  districts  than  where 
many  buildings  are  gathered  together. 

Pathology. — The  morbid  process  of  exudative  laryngitis  has 
been  already  considered  in  its  etiology.  It  only  remains  to  say  a 
few  words  as  to  its  histological  features. 

The  mucous  membrane  is  seen  to  be  always  more  or  less- 
hypersemic,  whether  in  the  simple  catarrhal  or  in  the  exudative 
variety ;  and  if  this  condition  is  not  universally  witnessed  on 
autopsy,  the  circumstance,  as  Niemeyer  has  shown,  is  principali;y 
*  due  to  the  richness  of  the  laryngeal  mucous  membrane  in  elast-i:> 
fibres,  which  remaining  extended  by  the  blood  contained  in  th'2 
vessels  during  life,  after  death  contract  and  expel  the  contents  of 
the  capillaries.' 

The  exudation,  when  present,  is  usually  composed  of  two  layers, 
a  superficial  and  a  deep  ;  the  former  consists  of  the  thickened 
original  epithelium  layer,  whose  cells  have  undergone  proliferatior^ 


IDIOPATHIC  CROUP. 


325 


and  mucoid  degeneration,  in  fact  so-called  catarrhal  changes ;  the 
deeper  layer  is  seen  under  the  microscope  to  be  composed  of 
a  number  of  strata  of  fibrinous  or  membranous  material  often 
enclosing  leucocytes.  In  some  circumstances  the  exudation  is 
pultaceous,  instead  of  being  fibrinous  or  membranous.  In  these 
less  advanced  patches,  therefore,  the  morbid  appearances  are 
mostly  superficial  to  the  basement  membrane,  which  is  superim- 
posed on  a  merely  hypersemic  submucous  tissue.  When  only  the 
superficial  layer  is  present,  we  have  the  catarrhal  variety,  while  the 
•deeper  exudation  layer  is  indicative  of  the  fibrinous  kind.  In  the 
more  rare  and  graver  cases,  the  so-called  suppurative  variety,  the 
submucous  tissue  in  addition  is  swollen ;  its  meshes  are  filled  with 
fibrinous  coagulated  matter  and  leucocytes  ;  and  in  time  the  vessels 
become  blocked  ;  circumferential  necrosis  takes  place,  with  the 
result  that  the  sequestrum  or  '  false  membrane '  is  thrown  off.  As 
will  be  seen  in  the  next  chapter,  the  whole  process  differs  in  no 
■essential  feature,  anatomical  or  microscopic,  from  what  takes  place 
in  diphtheria ;  but  it  may  be  noted  that  the  membrane  of  croup 
is  not  capable  of  reproducing  the  disease  by  inoculation,  as  has 
l)een  proved  to  occur  on  similar  experiment  with  diphtheritic 
Tnembrane.  Allusion  may  here  be  made  also  to  the  question  of 
micrococci  in  the  membrane  of  true  croup.  The  subject  is  dis- 
cussed at  greater  length  in  considering  the  pathology  of  diphtheria, 
and  no  more  can  now  be  said  than  that  they  are  less  frequently 
found,  and  in  fewer  numbers,  in  croup  than  in  diphtheria,  and  in 
the  larynx  than  in  the  fauces.  On  the  other  hand,  they  have 
been  witnessed,  at  an  early  period,  on  false  membrane  produced 
artificially  by  the  caustic  action  of  liquor  ammonise. 

Symptoms  :  A.  Functional. — Although,  as  a  rule,  some  pre- 
monition is  given  in  the  shape  of  shght  fever,  coryza,  and  othei- 
signs  of  a  common  cold,  change  of  voice  is  often  the  first  charac- 
teristic symptom  of  croup,  and  it  may  precede  those  of  a  more 
alarming  nature.  Beginning  as  a  simple  catarrhal  hoarseness,  it 
is  soon  observed  to  assume  a  metallic  timbre  and  to  be  raised  in 
pitch.    In  the  later  stages  it  becomes  completely  suppressed. 

Embarrassment  of  respiration  is  at  once  the  most  serious  and 
distinctive  evidence  of  croup.  Sometimes  two  or  three  days — 
more  often  only  a  few  hours — after  the  first  warning  of  any  disorder 
of  the  health,  the  little  patient  will  be  awoke  from  sleep  near  to 
midnight  with  an  attack  of  paroxysmal  dyspnoea  of  the  most 
painful  and  alarming  character.  Amongst  the  first  causes  of 
respiratory  distress  is  the  impediment  to  entrance  of  air,  this 
being  in  the  early  stages  due  to  pure  spasm  of  the  laryngeal  and 


336 


DISEASES  OF  THE  THROAT  AND  NOSE. 


tracheal  muscles,  voluntary  and  involuntary ;  later,  it  may  be 
caused  by  mechanical  obstruction  from  the  presence  of  false 
membrane.  As  a  result  of  this  impediment  the  inspiration  is. 
markedly  prolonged  and  consequently  of  diminished  frequency. 
Each  inspiration  is  attended  by  a  peculiar  stridor  which  con- 
stitutes one  of  the  most  marked  characteristics  of  the  disease. 
This  stridor  has  been  variously  described  as  high-pitched,  piping,, 
shrill,  metallic,  sibilant,  and  wheezing.  It  is  also  generally 
likened  to  the  crowing  of  a  cock,  and  it  is  from  this  resemblance 
that  the  disease  derives  its  appellation  of  ^  croup,'  the  word  being- 
applied  also  in  its  adjectival  qualification  to  sym.ptoms  of  cough 
and  respiration  when  partaking  of  this  character,  though  occuT^ 
ring  in  connection  with  diseases  of  a  quite  different  nature.  An 
anatomical  peculiarity  of  the  dyspnoea  is  the  indrawing  of  all  the 
muscles,  both  supra-  and  sub-sternal,  as  also  of  the  epigastrium, 
the  false  ribs,  and  even  the  lower  portion  of  the  breast-bone  itself 
— of  those  parts,  in  fact,  which  would  generally  be  distended  in 
healthy  inspiration.  It  is  useful  to  note  that  in  rickety  childiea 
the  diagnostic  importance  of  these  phenomena  may  easily  be 
exaggerated. 

All  these  respiratory  muscles  of  the  chest  and  abdomen,  regular 
as  well  as  auxiliary,  are  observed  during  the  spasm  to  work  pain- 
fully ;  the  nostrils  are  dilated,  and  the  whole  expression  and 
movements  of  the  face  and  limbs  give  evidence  of  a  laborious, 
struggle  for  breath.  The  complexion  becomes  turgid,  and  even 
livid,  and  death  from  apnoea  appears  imminent,  and  may  even 
occur.  In  happier  circumstances  the  paroxysm  may  be  some- 
what modified,  to  again  quickly  recur,  so  that  it  may  last  alto- 
gether for  an  hour  or  more.  As  the  spasm  passes  off  the  little- 
sufferer  will  fall  back  exhausted,  or  subside  into  a  restless  sleep,, 
from  which  he  will  again  be  aroused,  it  may  be,  in  a  few  minutes, 
or — in  the  earlier  stages,  during  the  day,  and  on  subsidence  of  the 
disease — at  intervals  which  extend  to  several  hours.  In  all  cases 
the  attacks  are  both  more  frequent  and  more  serious  during  the 
night  than  in  the  day ;  diminution  in  the  periods  of  remission  is 
an  unfailing  evidence  that  the  disease  is  progressing  unfavourably. 

Accompanying,  and  often  preceding,  distress  of  breathing  is 
the  symptom  of  cough,  also  one  of  a  most  distinctive  character.. 
It  has  a  high-pitched,  metallic,  and  ringing  sound,  generally 
denominated  *  brassy  '  or  *  laryngeal,'  and  once  heard  is  speedily 
recognised  even  by  the  non-medical  ear.  This  noisy  character  is,, 
however,  gradually  muffled,  and  may  be  completeK'  suppressed 
with  advance  of  the  malady,  so  that,  as  Cohen  says,  'the  child  will 


IDIOPATHIC  CROUP, 


be  seen  to  cough  without  making  noise  enough  to  attract  attention.' 
The  cough  is  unproductive  of  expectoration  in  the  early  stages  of 
any  case,  except  of  scanty  mucus  of  glairy  viscidity,  and  also  at  a 
later  period,  when  the  disease  is  not  progressing  towards  recovery; 
but  where,  as  in  favourable  circumstances,  the  membrane  is 
thrown  off,  large  flakes  or  even  complete  casts  of  portions  of  the 
air-passages  will  be  expectorated,  and  the  metallic  sound  of  the 
cough  will  become  changed  to  the  moist  tone  of  a  remitting 
laryngitis  or  bronchitis. 

Difficulty  in  deglutition  is  not  a  frequent,  or  by  any  means 
a  marked  symptom,  but  the  throat  is  naturally  very  sore,  and  the 
act  of  swallowing  is  therefore  somewhat  painful. 

There  is,  moreover,  very  distinct  tenderness  of  the  throat  on 
even  slight  external  palpation  of  the  larynx  and  trachea.  The 
fact  that  the  child  during  an  attack  frequently  clutches  at  the 
throat  might  appear  to  indicate  existence  of  actual  pain.  It  is 
probable,  however,  that  this  act  is  rather  suggestive  of  an  effort 
to  dislodge  the  source  of  impediment  to  breathing,  for  very  young 
children  will  often  be  seen  to  thrust  their  fingers  far  in  their 
mouth,  as  if  for  that  purpose ;  and  others  may  be  witnessed 
endeavouring  to  promote  vomiting  by  tickling  the  back  of  their 
throat. 

B.  Physical. — A  laryngoscopic  examination  is  by  no  means  an 
easy  matter  in  the  case  of  an  infant  or  very  young  child  attacked 
seriously  with  croup  ;  but  if  it  can  be  made,  the  diagnosis,  which 
has  in  all  probability  been  already  formed  by  observance  of  the 
functional  symptoms,  will  be  strengthened. 

The  normal  colour  of  the  larynx  will  be  seen  to  be  intensified  by 
inflammation ;  the  form  of  the  glottic  chink  may  be  narrowed  by 
swelling,  and  by  the  presence  of  false  membrane  of  a  white 
pellucid  appearance  ;  but  failure  to  discover  false  membrane  in 
the  larynx  by  no  means  implies  that  there  is  not  exudation  in  the 
infra-glottic  region. 

Mobility  of  the  laryngeal  respiratory  muscles  may  be  impaired 
independently  of  the  spasm. 

The  fauces,  tonsils,  and  pharynx  will  also  be  uniformly  inflamed 
in  varying  degree,  and,  rarely ^  membrane  may  be  seen  on  their 
surface.  This  may  be  due  to  temporary  lodgment  of  a  piece 
coughed  up  from  the  lower  passages.  An  actual  exudation  in 
this  region,  either  anterior  or  subsequent  to  laryngeal  symptoms, 
would  indicate,  to  my  mind,  the  probability  that  the  case  w^as 
one  of  diphtheria.  This  point  is,  however,  not  conceded  by 
Fagge,  who  will  only  '  admit  that  in  very  rare  cases  a  diphtheria 


328 


DISEASES  OF  THE  THROAT  AND  NOSE. 


may  begin  in,  and  remain  limited  to,  the  air-passages  ;  but  he 
thinks  it  very  much  more  often  happens  that  a  non-specific 
membranous  croup  extends  to  the  tonsils  and  palate.* 

Whenever  membrane  is  expelled,  the  surface  of  the  epithelium 
whence  it  is  shed  is  denuded  ;  and  as  diphtheria  may  be  developed 
on  an  abraded  skin,  so  it  is  quite  possible  that  in  certain  circum- 
stances the  same  may  take  place  as  a  secondary  development  in 
a  case  of  croup.  Indeed,  the  almost  invariable  pre-existence 
of  a  high  grade  of  hyperasmia  in  diphtheria  has  led  to  the  sugges- 
tion that  not  a  few  cases  of  this  disease  originate  by  septic  causes 
superposed  on  a  simple  catarrh. 

Where  examination  of  the  throat  is  not  possible,  the  presBtK:e 
in  the  expectoration  of  exuded  flakes  and  casts  will  be  the  chief 
physical  sign  on  which  dependence  can  be  placed. 

C.  Miscellaneous  symptoms  of  croup  are  important  and 
distinctive.  The  pulse,  at  first  quick  and  full,  becomes  strong 
and  bounding.  The  temperature,  though  high  (102°  to  104°  F.),  is 
not  subject  to  the  frequent  variations  of  diphtheria,  and  has  a 
tendency  to  abate  as  exudation  is  poured  out.  Thirst  is  a  promi- 
nent symptom,  and  the  patient  is  irritable,  restless,  and  anxious., 
Albumen  is  rarely  to  be  found  in  the  urine,  and  when  present 
has  no  more  significance  than  as  an  indication  of  the  temporary 
increase  of  blood-pressure  in  the  renal  capillaries,  often  associated 
with  pulmonary  complications.  There  is  never  any  evidence  of 
nephritis ;  recovery  is  not  retarded  by  such  sequelce  as  paralyses  ; 
the  glands  of  the  neck  are  not,  as  a  rule,  enlarged  or  painful. 

Diagnosis. — Postponing  consideration  of  the  differences  be- 
tween croup  and  diphtheria  until  after  description  of  the  latter 
disease,  it  is  difficult  to  see  with  what  other  affection  it  can  be 
confounded.  The  history  of  the  attack,  the  absence  of  fever  and 
cough,  and  the  complete  remission  of  all  symptoms  between  the 
attacks  which  distinguish  laryngismus  stridulus,  or  false  croup,  are 
sufficient  to  prevent  the  graver  from  being  mistaken  for  the  milder 
malady. 

With  regard  to  the  analogy  between  infantile  croup  and  adult 
laryngitis,  Aitken  says  that  the  latter  *  is  marked  by  the  same 
difficulty  of  breathing,  the  same  constriction  of  the  throat,  the 
same  parox3^smal  attack,  and  by  the  same  exemption  from  any 
severe  constitutional  affection.' 

Prognosis,  Course,  and  Termination. — Even  mild  attacks 
of  croup  should  give  cause  for  anxiety,  for  neglect  of  a  simple 
case  has  frequently  been  followed  by  aggravation  of  the  malady, 
and  by  a  suddenly  fatal  termination. 


IDIOPATHIC  CROUP, 


Mortality  from  membranous  laryngitis  in  the  child  is  very  great, 
and  it  is  generally  agreed  that  as  many  as  50 — Fagge  says  60  to 
70 — per  cent,  of  those  attacked  succumb ;  while  as  many  as  8  per 
'Cent,  of  all  deaths  between  the  ages  of  two  and  seven  years  are 
stated  by  some  authors  to  be  due  to  this  disease.  Age  is  an 
important  element  in  prognosis  ;  the  older  the  child  the  more 
favourable  is  the  chance  of  its  recovery.  The  greatly  diminished 
number  of  cases  of  croup  in  more  modern  returns  illustrates,  in 
a  marked  manner,  the  hold  that  the  doctrine  of  identity  of  it 
with  diphtheria  has  taken  in  the  profession.  Nor  could  it  be 
otherwise,  since  so  many  teachers  in  schools  are  of  that  opinion. 
Among  country  practitioners,  however,  the  contrary  view  is  firmly 
held.  It  is,  of  course,  very  probable  that  before  any  attempt  was 
made  to  separate  the  idiopathic  and  the  septic  forms  of  exudative 
laryngitis  many  cases  of  death  from  laryngo-tracheal  diphtheria 
were  recorded  as  croup.  In  the  present  day  it  is  equally  likely 
that  a  mistake  is  made  in  the  contrary  direction. 

In  the  course  of  the  disease  towards  restoration  to  health 
gradual  separation  of  the  membrane  takes  place,  followed  by  free 
mucous  expectoration  and  diminution  in  the  severity  and  stridulous 
•character  of  the  cough  and  respiration.  In  milder  cases  there 
may  be  no  objective  evidence  of  membrane  at  all,  the  exudation 
having  either  not  arrived  at  the  stage  of  fibrinous  deposit,  or 
having  become  pultaceous  before  release. 

The  duration  of  a  case  in  its  acute  form  is  from  four  to  ten 
days ;  complete  recovery  being  delayed  to  a  month  or  five  weeks ; 
and  in  some  instances  being  followed  by  one  or  more  relapses. 

When  the  disease  takes  an  unfavourable  course,  the  paroxysms 
become  more  frequent  and  almost  unremitting;  the  cough,  although 
toneless,  is  more  distressful ;  the  pulse-beats  are  more  rapid,  the 
little  patient  is  more  restless,  and  the  extremities  become  cold  ; 
finally  they,  as  well  as  the  countenance,  become  C3/anotic. 

The  fatal  issue  may  occur  in  any  of  the  following  ways :  by 
apnoea,  or  by  convulsions  during  a  paroxysm  of  dyspnoea;  b}'- 
asphyxia  through  actual  blocking  of  the  air -passages  with 
membrane,  or  by  carbonic  acid  poisoning ;  by  deposit  of  fibrin  in 
the  heart ;  by  exhaustion  and  coma ;  and  finally  by  secondary 
lung-comphcations.  The  date  of  a  fatal  termination  is  seldom 
extended  beyond  the  fourth  or  fifth  day,  unless  tracheotomy  has 
been  performed,  in  which  case,  even  if  fife  be  not  saved,  death 
may  be  somewhat  delayed. 

Regarding  the  convulsive  nature  of  the  paroxysms,  ^^Ferriar 
has  reported  a  case  in  which  the  struggle  was  so  violent  that 


DISEASES  OF  THE  THROAT  AND  NOSE, 


after  death  the  corpse,  in  a  great  measure,  rested  on  the  occiput 
and  on  the  heels. 

Treatment  of  croup  requires  to  be  pursued  with  energy  and 
discretion  from  the  first.  Probably  few  practitioners  now  employ 
bleeding  followed  by  blisters,  and  administration  of  mcrctLry  to  the 
extent  of  three  or  four  grains  of  calomel  with  antimony  every  few 
hours,  or  active  mercurial  inunction ;  yet  such  was  the  teaching  in 
quite  recent  times.  Of  general  measures  of  traditional  repute 
there  is,  however,  much  to  be  said  in  favour  of  an  emetic  given  at 
the  first  onset  of  an  attack,  and  it  is  indicated  on  the  following 
grounds  :  i.  There  is  reason  to  believe  that  irritation  of  the 
gastric  portion  of  the  vagus  may  play  some  part  in  predisposing 
to  true  croup  as  it  does  to  false.  2.  An  emetic  not  only  relieves 
a  possibly  overloaded  stomach,  but  it  also  favours  a  prompt  alvine 
evacuation,  diaphoresis,  diuresis,  and  a  diminution  of  the  febrile 
state  generally.  3.  Should  membrane  be  formed  in  the  trachea 
or  bronchi,  as  is  not  unfrequently  the  case  before  the  manifestation 
of  laryngeal  symptoms,  an  emetic  may  possibly  favour  its  ex- 
pectoration. The  best  form  of  emetic  is  ipecacuanha,  with  a 
small  portion  of  tartar  emetic — say  five  grains  of  the  former  with 
a  quarter  of  a  grain  of  the  latter  to  a  child  from  two  to  five  years- 
of  age,  moderating  the  dose  according  to  circumstances.  By 
some  the  hypodermic  administration  of  apomorphia  may  be  con- 
sidered preferable ;  the  dose  for  a  child  of  from  two  to  seven 
years  old  is  one-twentieth  to  one-tenth  of  a  grain  ;  the  solution 
must  be  made  fresh. 

Emetics  are  not  to  be  repeated  continuously,  as  is,  by  many, 
recommended,  but  may  be  administered  with  advantage  in  later 
stages  where  evidence  of  false  membrane  is  unmistakable,  but 
where  its  elimination  is  difficult.  For  this  purpose  sulphate  of 
copper  is  preferred  to  ipecacuanha  by  Niemeyer,  who  recom- 
mends two  to  five  grains  to  be  dissolved  in  an  ounce  of  water,  of 
which  a  teaspoonful  is  given  every  ten  minutes  until  emesis  is 
produced.  Personally,  I  should  be  afraid  to  give  this  remedy  to 
young  children,  for  fear  of  inducing  enteritis  ;  I  would  also  caution 
against  repeating  emetics  in  cases  where  reflex  action  has  become 
enfeebled,  lest  on  recovery — say  after  tracheotomy — the  reactior 
be  attended  by  dangerous  and  even  fatal  consequences. 

If  the  pulse  continues  full,  and  the  paroxysms  are  not  reduced, 
I  would  prescribe  half  or  one  grain  doses  of  calomel  with  two  of 
James's  powder  and  half  a  grain  of  Dover's  every  one  or  two 
hours  for  four  to  six  doses. 

From  experience  of  pilocarpine  in  other  diseases  it  is  probable 


IDIOPATHIC  CROUP. 


331 


that  hypodermic  injection  of  a  solution  of  this  drug  in  doses  of 
one-twelfth  of  a  grain  might  be  of  service.  Aconite  in  quarter  or 
half  minim  doses  every  fifteen  to  thirty  minutes,  till  the  tempera- 
ture is  reduced  and  the  heart's  action  lowered,  is  also  valuable  in 
early  stages. 

Beyond  giving  barley-water  as  the  principal  beverage  (in  which 
may  be  dissolved  bromide  of  sodium  or  ammonium),  or  warm 
milk  with  lime-water,  I  would  advise  no  other  internal  remedy. 
Dundas  Grant  reports  to  me  that  an  old  practitioner,  with  whom 
he  was  long  associated,  treated  croup  with  great  success  on  the 
following  routine  :  A  grain  of  calomel  every  four  or  six  hours, 
and  a  mixture  containing  3  to  5  minims  of  ipecacuanha  wine  and 
3  tc  5  grains  of  bromide  of  potassium  every  two  hours. 

Locally,  hot  poultices,  stupes,  and  sponges  are  still  in  vogue ; 
but  I  prefer  the  application  of  continuous  cold  externally  by  the 
Leiter  coil,  already  so  frequently  advocated.  This  application 
does  not  allow  cold  moisture  to  drip  down  the  neck  and  chest, 
nor  does  it  damp  the  night-dress  and  sheets  as  do  cold  cloths,  or 
ice  bladders.  On  the  other  hand,  it  is  quite  as  easily  retained  as 
a  poultice  or  sponge,  and  in  the  more  recent  form  of  its  inventor 
is  of  no  great  weight.  Whether  for  the  purpose  of  reducing  the 
inflammation,  of  modifying  the  spasm,  or  of  favouring  rapid 
separation  of  the  membrane,  application  of  continuous  dry  cold 
is  to  be  preferred  to  that  of  moist  heat,  which  is  almost  always 
followed  by  chill ;  and  should  warm  applications  be  preferred  to 
cold,  they  can  equally  well  be  applied  by  the  coil. 

There  is  a  general  consensus  in  favour  of  an  atmosphere  hyper- 
saturated  with  steam ;  but  I  am  inclined  to  think  that  this  treat- 
m.ent  is  often  carried  to  excess. 

The  bed  should  be  curtained,  and  vapour  brought  near  it  by 
means  of  a  steam-kettle,  but  the  croup  tented-bed,  which  gives 
the  little  patient  a  continuous  vapour  bath,  is  as  unnecessary  as 
it  is  depressing.  If  vapour  is  required  to  be  brought  nearer  to 
the  child's  mouth,  that  purpose  is  best  effected  by  a  steam 
draught  inhaler  with  plain  water,  or  with  benzoin  and  chloroform 
(Form.  30).    Such  an  inhalation  may  be  frequently  repeated. 

Nor  do  I  prescribe  applications  of  solutions  of  nitrate  of  silver, 
so  strongly  recommended  by  Niemeyer,  or  of  other  mineral ;  for 
such  apphcations,  however  mild,  especially  the  first-named,  are 
provocative,  not  only  of  spasm,  but  of  coagulation  of  the  ordinary 
secretions  of  the  mucous  membrane.  The  use  of  the  croup 
brush  is  also  to  be  carefully  avoided,  unless  the  practitioner  is 
ciuite  prepared  to  perform  tracheotomy  immediately  afterwards^  for  the 


332 


DISEASES  OF  THE  THROAT  AND  NOSE. 


forcible  disturbance  of  membrane  is  very  apt  to  block  up  the 
narrow  glottic  chink,  and  so  to  lead  to  serious  and  even  fatal 
suffocation,  and  this  quite  apart  from  the  dangers  of  spasm.  The 
same  caution  is  to  be  observed  in  relation  to  attempts  at  '  intuba- 
tion,' which  is  elsewhere  considered  at  greater  length.  Cohen 
advocates  lime-water  spray  inhalations  for  the  purpose  of  dis- 
solving the  membrane ;  but  it  is  doubtful  whether  they  ever 
reach  the  seat  of  exudation  until  it  has  extended  upwards  into 
the  larynx,  whereas  we  know  that  in  many  cases  the  supra- 
glottic  region,  although  the  seat  of  intense  inflammation,  may 
give  no  evidence  at  all  of  the  presence  of  membrane.  Applica- 
tions of  cocaine  by  spray  or  brush  would  also,  in  all  probability, 
fail  to  reach  the  seat  of  disease  independently  of  the  difficulty  of 
their  administration ;  but  hypodermic  injection  of  very  small 
doses — say  l\ij.  to  T{[y.  of  a  4  per  cent,  solution — in  the  neigh- 
bourhood of  the  larynx  would,  by  analogy,  be  of  double  service 
in  allaying  the  spasm  and  in  slowing  the  pulse. 

Operative  measures  consist  mainly  in  performance  of  tracheo- 
tomy, and  in  subsequent  attempts  to  clear  the  air-passages  of 
membrane  below  the  tracheal  opening.  These  points  will  be 
better  considered  in  detail  at  the  end  of  the  next  chapter  in 
relation  to  diphtheria,  and  it  is  sufficient  to  say  here  that  the 
procedure  to  be  successful  must  be  adopted  early.  It  only 
remains  to  say  a  few  words  regarding 

Hygienic  and  prophylactic  treatment.  Having  seen  how 
powerful  is  the  noxious  influence  of  cold  as  an  etiological  factor 
of  croup,  it  naturally  foHows  that  the  greatest  care  must  be  taken 
during  the  convalescence  of  a  child  subjected  to  an  attack,  as  to 
a  properly  warm  atmosphere  of  his  sleeping  and  living  rooms, 
protection  from  draughts,  equable  distribution  of  clothing,  and 
from  exposure  by  outdoor  exercise  to  the  unfavourable  influences 
of  inclement  weather  ;  and  these  hints  apply  equally  to  the  in- 
surance of  immunity  from  recurrence,  and  as  prophylactic  in  the 
case  of  those  children  who  may  be  predisposed  to  croup.  Atten- 
tion should  also  be  directed  to  correction  of  any  of  the  con- 
stitutional diatheses  to  which  we  have  referred  as  offering  a 
tendency  to  croupous  inflammations,  and  suitable  treatment 
should  be  adopted  for  the  eradication  of  adenoid  growths,  or  any 
other  local  condition  of  the  throat  favouring  catarrh. 


TRAUMATIC  CROUP. 


333 


TRAUMATIC  CROUP. 

This  condition  does  not  require  lengthy  consideration.  We  have 
already,  at  p.  302,  alluded  to  the  nature  of  the  injuries  and  poisons 
which  will  induce  membranous  exudation  of  the  mucous  mem- 
brane of  the  air-passages.  Such  a  condition  is  generally  seen  in  the 
case  of  children,  whereas  similar  causes  will,  in  the  adult,  be  more 
frequently  followed  by  submucous  infiltration  and  acute  oedema. 

The  SYMPTOMS  are  in  no  way  different  from  those  of  idiopathic 
croup,  except  that  general  pain  in  the  region  of  the  throat  and 
larynx  is  naturally  greater,  and  that  the  act  of  deglutition  is 
especially  difficult  and  distressful.  Respiration  is  impeded  by  the 
presence  of  the  false  membrane,  and  also  by  spasm  independently 
of  mechanical  obstruction,  for  many  fatal  cases  have  been 
recorded  in  which  no  exudation  has  been  found  below  the  level 
of  the  epiglottis.  Where  the  vocal  cords  are  involved,  the  voice 
will  be  reduced  to  a  mere  whisper,  and  cough  will  be  frequent. 

The  case  which  ^^Dr.  Whitehead  Reid  has  so  carefully  recorded 
in  the  Medico-Chirurgical  Transactions  is  one  of  great  interest  in 
several  particulars  :  The  patient  was  a  lady,  aged  27,  who  by 
accident  received  some  eau  de  Cologne  into  her  trachea  by  her 
nostril.  It  is  to  be  noted  that — i.  Membrane  was  profusely 
developed  on  the  third  day,  showing  that  traumation  of  this 
nature  has  the  power  to  produce  exudation  of  equally  strong 
consistence  as  diphtheria  even  in  the  adult.  2.  In  addition  to 
the  foregoing  there  was  laryngeal  oedema.  3.  There  were  no 
enlarged  glands.  4.  On  the  fifth  day  a  perfect  *  cast '  of  the 
larynx,  trachea,  and  upper  part  of  the  left  bronchus  was  expelled 
entire,  in  one  piece,  with  immediate  and  great  relief,  her  voice 
returning  at  once.  5.  In  three  weeks  from  the  accident  she 
could  sing  again.  6.  There  was  never  any  paralysis.  7.  The 
urine  never  contained  albumen,  although  respiratory  obstruction 
and  distress  had  been  extreme.  8.  All  possibihty  of  the  co- 
existence of  the  poison  of  scarlatina,  typhoid,  or  diphtheria  was 
negatived.  9.  Neither  of  her  young  children,  who  were  con- 
stantly with  her,  became  ill.  10.  The  microscopical  features  of 
the  membrane  were  similar  to  those  of  diphtheritic  exudation. 

Prognosis. — Recovery  from  traumatic  croup  is  rare,  and  de- 
pends on  the  age  of  the  patient,  on  the  nature  of  the  traumatism, 
the  extent  of  air-passages  involved,  and  last,  but  not  least,  on  the 
promptitude  with  which  active  remedial  measures  are  adopted ; 
failure  in  this  last  respect  not  being  by  any  means  often  the  fault 
of  the  medical  adviser,  but  of  the  parents  who  are  loth  to  give 


DISEASES  OF  THE  THROAT  AND  NOSE, 


permission  for  performance  of  operative  measures  until  the  chance 
of  their  success  is  much  lessened  by  delay. 

Treatment  resolves  itself  mainly  into  a  prompt  performance 
of  tracheotomy  in  the  case  of  children,  and — it  may  be — in  adults 
also  ;  with  external  application  of  cold,  and  the  internal  adminis- 
tration of  emulcent  and  refrigerated  drinks.  There  is  generally 
great  prostration,  and  stimulants  by  enema  or  otherwise  should 
therefore  be  administered  early.  In  some  cases  food  will  require 
to  be  given  by  the  stomach-tube. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

title  of  work  referred  to. 

321 

I 

AlTKEN. 

0J>.  cit. 

321 

2 

Sir  Thomas  Watson. 

Lectures  on  the  Principles  of  Medicine. 

321 

3 

NiEMEYER. 

Op.  cit.,  vol.  i.,  pp.  15  and  470. 

[  Report  of  Scientific  Committee  of  Royal 

"721 

4 

Sir  George  Burrows. 

J     Med.  CJiir.  Soc.  on  the  Relations  betiveen 
\     Membranous  Croup  and  Diphtheria, 

(     p.  52.    London,  1879. 
Practice  of  Medicine,6i\i  ed.  London,  1869. 

321 

5 

Tanner. 

321 

6 

Broadbent, 

Ibid.,  7th  edition,  1875. 

321 

7 

Roberts. 

Op.  cit. 

321 

8 

WiLKS. 

Report  of  Royal  Med.  Chir.  Soc,  p.  62. 

321 

9 

Hilton  Fagge. 

^  Principles  and  Practice  of  Medicine.  Lon- 
\     don,  1886. 

321 

10 

Home. 

i  Inquiry  into  the  Nattire,  Caiise,  and  Curd 

\     of  Croup.    Edinburgh,  1765. 

Cheyne. 

Diseases  of  Ch ildren.    Ed i n bu i  gh ,  i Soi . 
j  Ziemssei^s  Cyclopccdia,  Englisli  transla- 

322 

12 

Oertel. 

1     tion,  vol.  ii. 

323 

13 

Cohen. 

Op.  cit.,  p.  460. 

329 

14 

Ferriar. 

1  Medical  Histories  and  Reflections,  p.  135. 
(     London,  1798. 

333 

15 

Whitehead  Reid. 

Report  of  Royal  Med.  Chir.  Soc.,^.  95  scq. 

CHAPTER  XVII. 


DIPHTHERIA. 

(Figs.  42  and  43,  Plate  V. ;  Fig.  55,  Plate  VI.  ;  and  Fig.  117,  Plate  XIV.) 

In  contradistinction  to  our  definition  of  croup  as  an  exudative 
or  membranous  inflammation  of  the  air-passages  only,  of  non- 
infectious and  non-contagious  character,  by  the  term  diphtheria 
is  understood  an  inflammation  both  of  the  pharynx  and  larynx, 
^vhich  is  equally  characterized  by  the  formation  of  exudation  of 
false  membrane ;  but  it  is  highly  coniagiouSy  and  it  exerts  a  power- 
ful influence  on  the  constitution. 

Etiology.— Nature  of  the  Contagium.— ^ Semple  'believes  it 
to  be  impossible,  with  our  present  knowledge,  to  recognise 
diphtheria  as  a  distinct  inflammatory  disease,'  although^  the 
contrary  view  is  held  by  aU  French  writers  from  ^  Bretonneau 
down  to  the  present  time.  Semple  decidedly  underrates  the 
inflammatory  phenomena,  both  local  and  constitutional,  of  the 
affection;  nevertheless,  the  great  analogy  of  its  course  and 
manifestations  to  the  general  specific  diseases  of  the  type  of 
scarlet  fever  and  typhoid,  has  long  caused  diphtheria  to  be 
reckoned  one  of  the  specific  zymotic  fevers  by  the  highest 
medical  authorities.  Its  contagiousness  has  accordingly  been 
explained  or  accounted  for  by  the  particular  theories  which  have 
from  time  to  time  been  in  vogue  concerning  the  nature  of  con- 
tagion. 

Most  English  writers  hold  the  view  that  diphtheria  is  a  con- 
stitutional specific  fever  with  local  manifestations,  primarily  and 
principally,  in  the  throat  and  larynx,  but  many  Continental  and 
American  authorities  regard  it  as  primarily  a  local  disease  with 
secondary  manifestations;  this  view  seems  to  me  the  more 
rational. 

'  The  tendency  in  this  country  at  the  present  day,  especially 
amongst  younger  and  more  advanced  pathologists,  is  to  accept 


336 


DISEASES  OF  THE  THROAT  AND  NOSE, 


provisionally  the  notion  that  diphtheria  is  at  first  a  local  disease 
associated  with  the  growth,  on  some  mucous  membrane  or 
abraded  spot,  of  micro-organisms.  During  the  course  of  an 
epidemic  it  is  supposed  that  spores  enter,  say,  the  mouth  of  an 
individual,  and  either  do  or  do  not  find  in  the  oral  secretions  ot 
such  individual,  after  being  challenged  by  the  scavenging  leuco- 
cytes, a  suitable  culture  medium.  If  the  nidtis  be  a  favourable 
one^the  microbes  germinate  on  the  mucous  membrane  of,  for 
example,  some  part  of  the  pharynx  or  fauces ;  as  reproduction 
proceeds  apace,  the  multiplied  organisms  in  the  course  of  from 
two  to  eight  days  pass  into  the  tissues,  and  this  invasion  soon 
results  in  those  pathological  changes  so  characteristic  of  diph- 
theria, the  false  membrane.  The  life  processes  of  the  multiplying 
microbes  are  accompanied  by  fermentative  changes  and  the 
production  of  poisonous  albumins  and  ptomaines,  which  pass 
'.nto  and  contaminate  the  blood ;  systemic  poisoning  is  thus 
accounted  for.' 

Thus  I  wrote  in  the  third  edition  of  this  work  (i8go),  and  it  is 
interesting  to  note  how  the  result  of  recent  researches  have  tended 
to  confirm  many  points  in  this  statement. 

The  bacillus  diphtheriae  was  first  identified  by  ^Klebs.  •*Loe£fler 
went  a  step  further,  and  isolated  the  specific  organism  in  pure 
cultivations.  These  observations  were  confirmed  by  Cornil  and 
Babes.  ^Emmerich  made  similar  cultivations,  and  succeeded  in 
reproducing  the  disease  by  inoculations.  ^Wood  and  Formad,  in 
1881,  went  over  the  same  ground,  and  verified  the  foregoing 
researches  by  a  very  careful  course  of  experiments  with  the 
Klebs-Loeffler  bacillus  during  an  epidemic  of  diphtheria  on  the 
borders  of  Lake  Michigan.  ^Roux  and  Yersin  were  the  first  to 
show  that  this  bacillus,  when  introduced  into  the  circulation  of 
a  rabbit,  produced  progressive  paralysis.  The  above  observers 
proved  that  the  bacillus  is  always  present  in  diphtheritic  mem- 
brane, that  it  is  limited  to  the  superficial  part  of  the  membrane, 
but  it  does  not  enter  the  body  further ;  and  when  subcutaneously 
inoculated  its  growth  is  limited  to  the  site  of  injection.  These 
facts  taken  together  would  appear  to  lead  irresistibly  to  the  con- 
clusion that  the  bacillus  diphtheric^  is  the  living  specific  contagium. 

But,  as  insisted  in  the  second  edition  (1887),  *  it  is  well  known 
that  there  are  other  concomitants  besides  microbes  in  all  putre- 
fying and  necrosing  decompositions,'  alluding,  of  course,  to  the 
presence  of  chemical  products  in  the  necrosing  false  membrane  of 
diphtheria.  Arguing  from  analogy,  I  was  inclined  to  the  view  that 
^  the  ]ife  processes  of  the  multiplying  microbes  were  accompanied 


DIPHTHERIA. 


337 


by  fermentative  changes  and  the  production  of  poisonous  albumins 
and  ptomaines  which  pass  into  and  contaminate  the  blood.'  The 
researches  of  Roux  and  Yersin,  Brieger  and  Frankel,  and  the 
more  recent  and  exact  investigations  of  ^Sidney  Martin,  have 
amply  proved  that  the  primary  infective  agent,  the  Klebs-Loeffler 
bacillus,  produces  chemical  poisons  which  include  at  least  three 
virulent  albumoses  and  a  somewhat  poisonous  organic  acid,  but 
ptomaines  have  not  up  to  the  present  been  isolated.  As  Martin 
puts  it,  the  bacillus  "  liberates  in  the  membrane  a  ferment  which, 
when  absorbed,  digests  the  proteids  of  the  body,  forming 
albumoses  and  an  organic  acid,"  and,  according  to  this  observer, 
the  ferment — the  secondary  infective  agent — especially  attacks 
stagnating  proteids  in  the  spleen.  In  diphtheria,  therefore,  in 
addition  to  a  specific  organism  we  have  to  deal  with  specific 
poisonous  chemical  products,  the  result  of  the  life  processes  of 
the  organism.  These  specific  poisons  have  also  been  experi- 
mentally obtained  by  pure  cultivations  outside  the  body,  and  have 
further  been  demonstrated  to  have  a  specific  poisonous  action  on 
the  peripheral  nerves  of  the  body,  leading  to  parenchymatous 
degeneration. 

In  addition  to  the  specific  action  on  the  nervous  system  these 
chemical  products  have  been  experimental^  proved  to  produce 
wasting  of  the  tissues  and  fatty  degeneration  of  the  heart.  Large 
doses  of  the  poisons  injected  into  animals  tend  usually  to  depress 
the  temperature,  but  small  doses  often  produce  but  a  slight  though 
prolonged  rise.  It  will  be  seen  that  the  prominent  symptoms  of 
diphtheria  are  due  (i)  to  mechanical  causes  associated  with  the 
growth  of  the  bacillus,  i.e..,  the  production  of  a  stenosing  fibrinous 
membrane,  and  (2)  to  chemical  poisons  causing  pathological 
changes  in  the  blood  and  tissues. 

In  this  connection  the  question  arises.  Why,  if  the  oral  secre- 
tions form  a  suitable  culture  medium  for  the  imdtiplicatioii  of  the 
organisms  (an  essential  feature  in  the  infecting  process),  is  it  that 
the  mucous  covering  of  the  tonsils  and  other  lymphoid  masses  is 
most  usually  the  area  invaded  by  the  microbes  ?  In  answer  to 
this  query,  it  may  be  pointed  out  that  the  tonsillar  mucous 
membrane  is  more  pervious  to  living  organisms  than  any  other 
because  of  the  diapedesis  of  leucocytes,  which  is  continually  going 
on  through  it.  Moreover,  the  crypts  of  the  tonsils  form  quiet  re- 
cesses for  the  incubation  and  subsequent  germination  of  microbes. 
It  is  probable  that  in  most  instances  where  those  exposed  to  in- 
fection have  not  contracted  the  disease,  the  leucocytes  secreted 
by  the  tonsils  have  checked  the  germination  of  the  organisms. 

22 


358 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Where,  on  the  other  hand,  the  tonsils  are  diseased,  phagocyte- 
production  is  diminished,  and  such  individuals  are  more  liable 
to  contract  the  disease  when  exposed  to  infection. 

Inoculability. — ''Trousseau  and  others  having  failed  in  certain 
experiments  made  on  themselves  and  on  rabbits,  the  inoculabiht}' 
of  diphtheria  w^as  at  one  time  disputed.  There  is  now,  however, 
no  doubt  that  the  disease  can  be  transmitted  by  the  application 
of  necrosing  membrane  to  mucous  or  abraded  cutaneous  surfaces. 
The  number  of  medical  victims  of  the  heroic,  but  none  the  less 
reprehensible,  practice  of  extracting  membrane  through  tracheo- 
tomy-tubes by  their  own  lips,  instead  of  applying  artificial  suction, 
is  a  striking  testimony  to  its  direct  contagiousness.  The  failure 
of  the  experiments  of  Trousseau  and  others  just  alluded  to  can 
be  readily  explained  by  our  own  view.  First,  that  diphtheritic 
contagium  requires  a  suitable  nidtis,  or  soil,  for  its  development ; 
and  secondly,  that  all  stages  of  the  exudation  are  not  equally 
active  in  their  infective  capacity. 

Our  first  proposition  will  be  readily  conceded,  and  is  proved  in 
a  measure  by  the  happy  miscarriage  of  Trousseau's  rash  experi- 
ments on  himself.  The  recent  investigations  of  ^^Renshaw  con- 
firm the  second ;  for  the  fact  that  many  animals,  especially  the 
carnivora,  can  be  infected  by  inoculation  with  a  portion  of 
diphtheritic  membrane  has  been  abundantly  proved ;  and  the 
author  just  named  has  conducted  a  series  of  highly  interesting 
experiments,  of  which  the  following  is  a  brief  resume.  Portions 
of  greyish-white  membrane  were  mixed  with  the  food  of  six  cats, 
and  in  every  case  the  disease  was  reproduced  with  the  charac- 
teristic lesions  and  symptoms.  Experiments  on  fourteen  cats, 
with  the  younger  yellowish-white  membrane,  and  with  grayish 
membrane  which  had  been  soaked  in  Condy's  Fluid,  or  in  hydro- 
chloric acid,  produced  only  negative  results.  This  observer  failed 
to  reproduce  membranous  laryngitis  (true  croup)  by  this  method. 
Experiments  v/ith  graminivorous  animals  were  not  successful. 
This  latter  fact  throws  light  on  the  cause  of  the  failure  of 
Trousseau's  experiments  on  rabbits,  though  it  is  to  be  mentioned 
that  Formad  and  Wood  succeeded  in  inoculating  rabbits  even 
with  cultivated  material.  It  only  remains  to  be  added  that 
diphtheria  has  been  communicated  to  human  beings  from  hens, 
pigeons,  calves,  and  various  domestic  animals. 

Mode  of  Origin  and  Dissemination. — Diphtheria  may  arise 
either  epidemically,  cndemically,  or  sporadically,  and  separately. 
There  can  be  little  doubt  that  these  distinctions  depend  on  some 
ill-defined  though  fairly  well  understood  insanitary  circumstance 


DIPHTHERIA. 


339 


of  region,  atmosphere,  or  individual  ;  for,  while  the  disease  will 
be  manifested  year  after  year  in  certain  towns,  streets,  or  districts, 
so  long  as  the  insanitary  condition  of  the  infected  neighbourhood 
is  neglected,  attention  in  that  direction  will  often  banish  the 
■disease,  to  reappear  if  the  laws  of  health  are  again  disobeyed. 
That  the  disease  may  be  eradicated  by  thorough  sanitation  is 
proved  by  the  fact  that  where,  as  is  not  unfrequently  the  case, 
diphtheria  appears  in  a  house  separated  from  others,  the  attack 
may  be  limited  to  one  individual  or  to  only  a  portion  of  the 
household,  and,  having  run  its  course,  will  never  reappear  in  that 
dwelling  provided  only  it  be  properly  *  swept  and  garnished.' 

Not  only  is  diphtheria  highly  contagious  to  those  in  attendance 
on  the  stricken  patient,  but  its  infecting  properties  may  be 
retained  for  months  in  tainted  clothing,  dwellings,  and  apart- 
ments. 

By  v/hat  agency  a  medical  attendant,  or  other  person, 
with  every  precaution  against  infection,  takes  the  disease  by 
merely  breathing  the  same  atmosphere  as  a  diphtheritic  patient 
for  only  a  few  minutes,  it  may  be — it  is  difficult  to  explain  ; 
— though  doubtless  it  might  be  advanced  that  in  most  of  such 
cases  the  conveyance  of  contagion  is  more  material  than  is  often 
admitted.  There  are,  however,  many  isolated  cases  which  can 
only  be  explained  by  supposing  that  germs  from  a  diphtheritic 
patch  contaminate  the  breath. 

Sporadic,  separate,  or  solitary  cases  of  diphtheria,  without 
obvious  exposure  to  previous  infection,  are  rare.  ^^Huebner's 
explanation  that  these  cases  arise  through  the  influence  of  cold, 
inducing  spasm  of  the  superficial  capillaries  of  the  pharynx,  to  be 
followed  by  complete  cessation  of  the  circulation  and  diphtheritic 
exudation,  is  certainly  suggestive  ;  but  in  such  a  case  the  hygienic 
surroundings  of  the  patient  must  presumably  be  favourable  for 
the  settling  and  development  of  bacterial  germs  on  the  exudation 
or  membrane  ;  microbic  decomposition  and  gangrene  of  the  latter, 
with  the  production  of  poisonous  chemical  excreta,  ptomaines, 
albumens,  albumoses,  or  what  not,  would,  according  to  this  view, 
explain  the  occurrence  of  secondary  symptoms  and  the  develop- 
ment of  systemic  infection.  If  it  could  be  shown  that  cases  do 
absolutely  arise  in  this  local  way,  and  afterwards  develop  systemic 
manifestations,  it  would  go  far  to  prove  the  correctness  of  the 
view  of  ^^Oertel,  ^-'Schech,  and  others,  that  diphtheria  may  be  in 
the  first  instance  a  local  disease. 

Chief  amongst  insanitary  causes  are  impurity  of  drinking- 
water  or  of  milk  (sometimes  tainted  by  dilution  with  impure 
water,  or  by  cleansing  of  the  pails  with  the  same),  defective  sewers, 


340 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ill-trapped  drains  leading  to  escape  of  sewer  gas,  soaking  of  the 
soil  with  sewage  poison,  and,  indeed,  all  those  conditions  con- 
sidered as  favourable  to  the  development  of  typhoid.  It  is  held 
by  some  as  unnecessary  that  the  poison  influencing  the  foregoing 
circumstances  should  invariably  be  that  of  diphtheria,  though  in^ 
all  probability  such  is  generally  the  case,  there  existing,  it  may  be,. 
a  separate  chemical  poison,  volatile  or  otherwise,  as  well  as  a^ 
separate  bacterium  for  each  variety  of  infectious  fever. 

The  contagium  remains  dormant  for  weeks  or  months,  and, 
according  to  some  authors,  for  even  years.  Regarding  these  sup- 
posed longer  periods  of  inactivity,  the  disease  is  perhaps  generated 
de  novo  in  the  way  previously  suggested. 

Season. — The  disease  is  certainly  more  frequent  in  the  winter — 
particularly  in  cold  damp  weather.  Epidemic  influenza  is  also  a 
probable  predisponent,  and  generally  it  may  be  stated  that  the 
atmospheric  influences  are  those  favourable  to  the  causation  of 
catarrhal  inflammations ;  but  it  cannot  be  denied  that  diphtheria 
occurs  at  any  period  of  the  year,  and  under  very  varying  influences 
of  wind  and  weather.  It  is  more  frequent  in  temperate  than  tropical 
climates.  Rural  districts  are  more  subject  to  the  disorder  than 
urban,  in  the  proportion,  says  ^''Thursfield,  of  three  to  one. 

During  a  visit  to  South  Africa  in  i88g.  Dr.  Herm.an,  of  Cape 
Town,  kindly  gave  me  some  interesting  notes  of  his  experience 
and  observations  in  that  country.  The  disease,  as  here,  is  most 
prevalent  in  the  damp  weather  of  autumn  and  winter,  and  in 
Cape  Town  has  presented  itself  as  isolated  cases  in  the  suburbs 
and  better  parts  of  the  city,  rather  than  in  the  insanitary  slums 
where  typhoid  is  of  course  common.  Dr.  Herman  has  always 
found  the  disease  in  proximity  to  *  manurial  and  vegetable 
deposits,'  or  to  *  cow-stables.'  He  points  out  that  diphtheria, 
which  is  rather  frequent  *  up  country,'  appears  in  isolated  farms 
in  the  sheep  and  cattle  districts,  where  the  animals  are  often 
herded  in  kraals,  and  where  decaying  refuse  is  not  only  in 
proximity  to  the  dwelling-houses,  but  also  close  enough  to  con- 
taminate the  water  supply.  My  own  experience  has  long  tended 
to  confirm  this  view,  first  put  forth  in  print  by  Renshaw,  that 
diphtheria  is  especially  apt  to  be  associated  with  the  proximity 
to  heaps  made  up  of  both  animal  and  vegetable  refuse.  I  have 
known  three  cases  in  which  an  attack  in  a  household  had  been 
preceded  by  a  manifestation  in  the  families  of  coachmen  in 
adjoining  stables.  In  one  other  instance  there  was  connection 
of  the  drainage  from  the  stables  wath  that  of  the  house  ;  and, 
lastly,  I  have  recently  had  knowledge  of  one  in  which  the  probable 
source  of  origin  was  a  very  insanitary  pigsty. 


DIPHTHERIA.  341 

Incubation. — The  experimental  incubation  period  when  com- 
municated by  inoculation  in  the  lower  animals  is  short,  and  varies 
from  one  to  three  days.  It  is  said  to  be  about  the  same  period 
when  a  human  patient  is  infected  by  direct  contact.  In  this  connec- 
tion ^^Leslie  Phillips  reports  a  very  interesting  case,  in  which 
some  of  the  same  instruments  were  used  on  the  same  day,  first  in 
the  operation  for  tracheotomy  for  diphtheria,  and  secondly  for 
circumcision  ;  the  circumcised  child  had  pseudo-membrane  on  the 
prepuce  on  the  fourth  day.  In  ordinary  circumstances  the  period 
between  exposure  to  the  contagion  of  infected  air  and  the  appear- 
ance of  false  membrane  is  from  two  to  eight  days. 

Age  is  an  important  factor  both  in  the  susceptibility  and  in  the 
gravity  of  the  disease,  for  while  about  10  to  12  per  cent,  of  children 
die  from  diphtheria  under  the  age  of  i  year,  over  33  per  cent,  are 
fatally  attacked  between  i  and  5  years,  and  about  20  per  cent, 
between  5  and  10  years.  Each  succeeding  decade  shows  diminu- 
tion in  both  liability  to  contagion  and  in  severity  of  the  attack 
when  manifested. 

No  doubt  an  anatomical  explanation,  viz.,  the  small  and  chink- 
like glottis  of  children,  will  account  in  some  degree  for  the  high 
infantile  mortality,  but  it  is  also  probable  that  the  delicate 
organizations  of  the  young  are  more  affected  than  in  the  case  of 
an  adult  by  the  virulence  of  the  poison,  be  it  a  ptomaine  or  what 
not ;  and  I  would  once  again  repeat  the  opinion  already  frequently 
expressed,  that  in  young  children  there  is  a  greater  tendency  for 
inflammations  of  the  air-passages  to  assume  an  exudative  mem- 
branous type — thrush,  plastic  bronchitis,  and  non-specific  mem- 
branous laryngitis  being  diseases  almost  entirely  confined  to  the 
period  of  childhood  and  adolescence. 

Constitution  is  not  thought  to  play  any  part  as  a  predisponent 
generally,  but,  without  doubt,  children  who  are  subject  to  naso- 
pharyngeal catarrhs  are  more  liable  to  take  diphtheria.  Those 
suffering  from  a  morbid  condition  of  the  tonsils  are  also  especially 
receptive  of  contagion,  for,  in  fact,  the  patches  nearly  always  first 
appear  on  the  faucial  tonsils.  I  have  experience  of  several  cases 
illustrating  it  from  two  aspects,  namely,  some  in  which  removal  of 
the  thickened  mucous  surfaces  of  enlarged  tonsils,  and  consequent 
restoration  of  function,  has  appeared  to  give  a  special  immunity 
to  the  disease,  and  others  in  which  my  advice  as  to  removal  of 
these  glands  and  accompanying  adenoids  having  been  neglected, 
diphtheria  has  been  specially  fatal.  It  may  be  remarked,  cn 
passant^  that  the  same  fact  holds  good  in  relation  to  scarlatina. 

My  advice  was  sought  by  my  friend  Mr.  Poyntz  Wright,  Medical  Officer  of  the  St. 
Neots  Local  Board  of  Health,  in  the  case  of  diphtheria  occurring  to  a  member  of  his  own 


:42  DISEASES  OE  THE  THROAT  AND  NOSE. 

family,  a  young  lady,  aged  24,  who  had  been  subject  to  'ulcerated  throat'  and  lacunar 
tonsillitis  ever  since  she  had  scarlatina  fifteen  years  previously.  Four  days  before  her 
attack,  the  patient  had  walked  across  a  turnip-field  which  had  recently  been  flooded.. 
She  experienced  great  nausea  from  the  horrible  stench  which  was  exhaled,  but  continued 
her  walk  to  a  sewage-farm,  where  she  gathered  some  moss  from  an  osier-bed.  On  the 
following  day  a  sharp  sickle-shaped  herring-bone  lodged  in  the  left  tonsil,  and  in  her 
endeavours  to  extract  it  broke  off  short.  Sore  throat  commenced  two  days  later,  and  oa 
the  next — the  fifth  from  her  visit  to  the  sewage-farm — membrane  appeared.  The  exuda- 
tion was  strictly  limited  to  the  left  side  of  the  fauces,  with  the  exception  of  o}je  small 
patch  of  membrane  on  the  right  tonsil.  On  the  sixth  day  there  was  complete  paralysis  of 
the  velum  on  the  left  side,  with  paresis  of  the  muscles  on  the  right.  A  friend  and  other 
children  of  the  same  family  who  had  been  walking  with  her  on  the  occasion  noted  were 
unattacked  ;  and  with  the  exception  of  one  (doubtful)  case  of  diphtheria  ten  miles  distant^ 
the  district  was  quite  free  from  the  disease. 

There  can  be  little  doubt  in  my  mind  that  in  this  case  the 
chronically  inflamed  condition  of  the  tonsils,  and  the  consequent 
abeyance  of  their  function  of  phagocyte-production  rendered  the 
patient  susceptible  to  the  noxious  influence  of  the  probable  microbic 
poison  of  the  decaying  turnips,  and  to  possible  germ  emanations 
from  the  osier-bed  at  the  sewage-farm,  and  that  the  herring-bone 
incited  to  more  thorough  introduction  of  the  poison.  The  para- 
lysis supervened  the  primary  manifestation  with  unusual  rapidity. 

The  following  curious  circumstance  is  worth  recording  in  this 
connection  of  constitutional  predisposition,  though  it  has  points 
of  interest  which  apply  to  other  considerations  of  etiology  ;  it 
has  also  an  especial  bearing  on  the  ptomaine  theory,  and  on  the 
prophylactic  influence  of  antiseptic  measures  : 

I  was  asked  in  July,  1885,  to  attend  a  young  lady  in  conjunction  with  Mr.  Henry  Bury, 
of  Whetstone.  The  patient  was  a  tall,  well-grown  girl  of  17,  and  of  good  constitution. 
She  resided  in  the  same  house  as,  and  was  the  constant  and  inseparable  companion  of, 
another  young  lady  of  the  same  age,  but  of  delicate  health,  who  had  for  some  years  been 
under  my  constant  care  on  account  of  strumous  ozcena,  for  the  relief  of  which  she 
diligently  employed  antiseptic  applications  in  the  shape  of  sprays,  douches,  and  ointments. 
There  were  other  cases  of  diphtheria  in  the  adjoining  stables  and  in  the  neighbourhood,, 
but  the  exact  cause  in  the  case  under  notice  was  believed  to  be  the  breathing  of  exhala- 
tions from  the  stagnant  and  foul  water  of  a  pond  where  the  two  girls  had  been  amusing 
themselves  catching  tadpoles,  etc.  Now  the  stronger  of  the  two  had  diphtheria  very 
virulently,  and  the  attack  was  followed  by  grave  and  protracted  paralysis.  The  delicate 
girl  who  was  employing  antiseptics  had  a  very  high  temperature  for  two  or  three  days,, 
and  was  prostrated  ;  but  she  exhibited  no  throat  symptoms  nor  sequela;  whatever. 

This  case  bears  an  indirect  relation  to  the  factor  next  to  be 
considered,  namely  : 

Social  Status. — Although  in  its  endemic  forin  diphtheria  is 
rarely  manifested  in  the  first  instance  in  houses  thoroughly 
efficient  in  sanitation,  it  will,  when  epidemic,  rage  equally 
amongst  both  rich  and  poor,  the  delicate  and  the  robust.  But 
it  has  appeared  to  me  that  when  diphtheria  attacks  members  of 
the  upper  classes,  it  is  often  more  malignant,  and  runs  a  more 
quickly  fatal  course  than  amongst  the  indigent  :  the  disease 


DIPHTHERIA, 


.3U 


finding,  as  it  were,  a  more  receptive  soil  in  the  person  of  those 
delicately  nurtured,  than  in  those  whose  systems  are  in  a  manner 
accustomed  to  insanitary  influences.  On  the  other  hand,  and  for 
obvious  reasons,  recovery  from  the  sequelae,  when  once  the  acute- 
ness  of  an  attack  has  passed  off,  is  more  expeditious  and  complete 
in  the  well-to-do. 

Pathology. — Anatomical  Characters.  Mucous  membrane 
of  Throat,  etc. — The  primary  local  manifestation  of  diphtheria 
usually  appears  as  an  inflammation  of  the  fauces,  not  necessarily 
uniform,  attended  with  exudation  which  proceeds  in  most  instances 
to  the  formation  of  false  membrane.  This  surface  inflammation 
of  the  throat  may  be  somewhat  mottled,  and  is  analogous  to  the 
ordinary  eruption  of  the  exanthemata  on  the  skin ;  cutaneous 
rashes  are  even  occasionally  observed  in  diphtheria.  The  inflam- 
matory redness  gradually  extends  over  the  entire  mucous  mem- 
brane of  the  back  of  the  throat,  but  the  deposit  may  commence  at 
any  one  spot — in  the  majority  of  cases  on  the  tonsils — or  at  several 
places  concurrently,  as  at  the  back  of  the  pharynx,  on  the  pillars 
of  the  fauces,  on  the  uvitla,  or  on  some  other  part  of  the  velum 
palati.  Later  it  may  spread  to  the  larynx,  trachea,  or  bronchi,  even 
to  the  finest  ramifications  of  the  latter.  Or  patches  may  appear 
on  the  mucous  membrane  of  the  buccal  cavity,  lips,  nose  and 
conjunctiva,  these  also  being  late  manifestations. 

Digestive  Tract,  etc. — In  some  rare  instances  it  is  found  on 
the  lining  membrane  of  the  oesophagus,  stomach,  intestines,  rectum, 
and  QYen  gall-bladder.  Very  exceptionally  it  starts  in,  or  is  limited 
to,  certain  of  these  parts.  Specimens  illustrating  diphtheria  of 
Peyer's  patches  have  quite  recently  been  added  to  the  Museum  of 
the  College  of  Surgeons,  these  lymphoid  masses  being  homologues 
of  the  tonsils.  I  have  more  than  once  m.et  with  cases  of  two 
individuals  dwelling  in  an  unsanitary  house,  the  one  of  whom  has 
had  typhoid  and  the  other  diphtheritic  symptoms.  The  same 
observation  has  been  made  as  regards  scarlet  fever.  ^ 

The  deposit  has  been  found  on  the  prepuce  of  the  male,  and  vulvo- 
vaginal tract  of  the  opposite  sex.  Diphtheritic  exudation,  how- 
ever, only  attacks  the  skin  at  abraded  spots,  such  as  eczematous 
fissures,  operation  wounds,  leech-bites,  and  blistered  surfaces.  ' 

16  Hill  has  recently  recorded  two  primary  cases  of  diphtheria  of  the  perineal  region 
whidi  occurred  in  a  father  and  daughter.  The  disease  was  supposed  to  be  contracted 
through  using  an  unsanitary  water-closet.  The  father,  aged  40,  had  false  membrane  on 
an  old  eczematous  patch  near  the  anus,  which  was  followed  by  typical  paralysis.  There 
was  no  false  membrane  in  the  throat.  The  daughter,  aged  9,  had  some  weeks  afterwards 
primary  diphtheria  on  the  vulva,  which  spread  to  the  vagina  and  perforated  the  recto- 
vaginal wall.  In  this  last  case  there  was  also  false  membrane  on  the  throat  which  ex- 
tended to  the  lungs,  causing  death.     '      ,  . 


341 


DISEASES  OF  THE  THROAT  AND  NOSE. 


In  addition  to  lesions  of  mucous  membrane,  other  organs  are 
often  profoundly  affected. 

Lungs.  —  Pathological  lesions  in  the  pulmonary  organs,  as 
exudative  and  other  forms  of  bronchitis,  lobar  and  lobular  pneu- 
monia, pulmonary  collapse,  etc.,  are  due  in  most  cases  either  to 
extension  of  the  membrane  from  the  larynx  into  the  lungs,  or  to 
a  stenotic  condition  of  the  glottis,  and  as  a  late  feature  of  the 
disease  we  may  here  mention  paralytic  engorgement. 

Kidneys. — The  almost  constant  symptom  of  albuminuria  points 
to  the  fact  that  the  kidney  suffers  in  its  endeavour  to  eliminate 
the  virus.  In  the  early  stage  of  the  disease  the  kidneys  are 
merely  in  a  state  of  hyperaemia ;  later  on,  however,  the  condition 
is  that  of  true  parenchymatous  nephritis,  with  cloudy  swelling, 
fatty  degeneration,  and  shedding  of  epithelial  cells.  These  latter, 
singly,  or  in  the  form  of  casts,  together  in  some  instances  with 
blood-corpuscles,  speedily  make  their  appearance  in  the  urine. 
Micrococci  and  bacteria  are  occasionally  to  be  found  in  sections 
of  the  renal  tissue ;  but  as  their  presence  is  not  constant,  they 
cannot  be  regarded  as  direct  excitants  of  the  nephritis. 

The  lymphatic  system  is  often  deeply  involved,  and  the  inflam- 
matory enlargement  and  occasional  suppuration  of  the  glands  at 
the  angle  of  the  jaw  is  of  diagnostic  importance  from  its  almost 
constant  occurrence  in  pharyngeal  diphtheria.  Haemorrhages  of 
the  Spleen  are  occasionally  observed  after  death  ;  and  exudative 
m.ilky  patches  have  been  recorded  as  present  on  its  surface,  as 
well  as  on  that  of  the  brain  and  heart.  The  proclivity  to  attack 
of  the  lymphoid  masses  lining  the  alimentary  tract  has  already 
been  alluded  to. 

Nervous  System. — ^''Buhl  found  capillary  haemorrhages  ;  and 
changes  in  the  cells  of  the  neuroglia  and  in  the  nuclei  of  the 
nerve-sheaths  of  the  spinal  cord  have  been  reported  in  cases  which 
had  exhibited  paralytic  sequelae. 

Heart. — Fatty  degeneration  is  not  very  frequently  observed 
post  mortem,  but  thrombotic  clots  in  the  ventricle,  aorta,  and 
pulmonary  artery  are  fairly  often  seen  in  those  cases  which  die 
in  the  acute  stage  with  marked  symptoms  of  asthenia.  Bacilli 
have  been  found  in  the  heart  muscle  in  at  least  one  case  brought 
to  my  knowledge. 

Histological  Features. — Turning  now  to  the  microscopic 
appearances  of  diphtheritic  lesions,  it  must  be  admitted  at  the 
outset,  as  mentioned  in  our  remarks  on  croup,  that  there  is 
nothing  absolutely  characteristic  or  pathognomonic  in  the  exuda- 
tion patches  and  false  membranes. 

There  can  be  little  doubt  that  the  same  causes  which  would 
give  rise  to  inflammation,  pustulation,  ulceration,  and  local 
sloughing  or  gangrene  on  the  skin,  will  lead,  in  the  case  of 


DIPHTHERIA, 


345 


mucoas  tracts,  first  to  hyper^emia  and  catarrh,  then  to  the  forma- 
tion of  the  white  exudation  patch,  and  lastl}^  to  necrosis  and 
false  membrane.  During  health  a  mucous  membrane  secretes  a 
serous  fluid  containing  mucin,  and  at  least  some  of  the  fibrin 
factors  ;  and  it  is  not  strange  that  when  such  a  tract  is  injured 

-  either  by  the  presence  of  a  specific  poison  or  by  any  of  the  before- 
mentioned  causes,  the  catarrhal  inflammatory  state  (consisting 
principally  of  cell-proliferation)  should  be  followed,  primarily,  by 
mucous  and  fibrinous  degeneration,  rather  than  by  fatty  changes 
and  suppuration,  which  are  only  the  last  stages  of  the  morbid 
phenomena.  These  later  changes  result  from  blocking  of  the 
vessels  and  their  degeneration,  causing  first  circumferential 
necrosis,  and  eventually  separation  of  the  so-called  false  mem- 
brane. It  is  probable  that  the  membranous  nature  of  the  lesion 
is  due  to  a  fibrinous  coagulation  which  is  caused  by  the  presence 
■of  the  chemical  poisons  excreted  by  the  invading  organism  ;  if  the 
poisons  themselves  do  not  actually  cause  coagulation  of  the  serum 
in  the  tissues,  it  is  conceivable  that  they  may  cause  disintegration 
of  leucocytes,  and  thus  set  free  some  of  the  fibrin  factors.  Until 
recently  it  was  believed  that  there  was  an  essential  difference  in 
the  structure  of  the  false  membranes  of  specific  diphtheria  and 
that  of  non-specific  membranous  laryngitis.  Thus  ^^Virchow's 
views  that  the  exudation  or  the  false  membrane  of  the  latter  is 
always  superficial  to  the  membrana  limitans,  whilst  that  of  the 
former  always  extends  to  the  deeper  layers,  have  been  adopted 
by  ^^Niemeyer,  and  have  been  quoted  over  and  over  again.  That 
this  is  not  correct  has  since  been  admitted  by  -^Virchow  and  by 
less  eminent  authors  ;  and  we  now  know  and  readily  understand 
that  there  must  be  an  apparent  want  of  similarity  between  a  por- 
tion of  pharyngeal  false  membrane  taken  from  a  case  of  diphtheria 
:and  a  portion  of  laryngeal  membrane  from  a  case  of  croup.  This, 
however,  is  due  to  the  fact  that  there  is  a  difference  in  the  normal 
histological  structure  of  the  mucous  lining  of  the  pharynx  and 
larynx,  viz.,  in  the  character  of  the  epithelium,  in  the  distribution 
of  the  glands,  and  in  the  relative  amounts  of  adenoid  tissue  and 
lymph-follicles  ;  but  there  is  no  essential  difference  between  laryn- 
.geal  false  membranes,  whether  of  specific  (diphtheritic)  or  non- 
specific (croupous)  origin.  The  greater  vascular  suppl}^  the  more 

'  serous  secretion,  and  the  large  amount  of  adenoid  tissue  and 
lymph-follicles  in  the  pharynx,  account  for  the  more  fibrinous 
■character  of  the  exudation,  and  for  the  frequent  sub-epithelial 
cellular  infiltration  in  pharyngeal  patches  and  false  membranes. 

Under  the  microscope  an  ordinary  diphtheritic  exudation  patch, 
at  a  stage  prior  to  any  naked-eye  evidence  of  even  partial 
detachment,  presents  pretty  constantly  two  layers,  a  superficial 


346 


DISEASES  OF  THE  THROAT  AND  NOSE, 


and  a  deep.  The  former  is  made  up  of  a  number  of  strata  of 
epithelium  cells,  evidently  consisting  of  the  original  epithelium 
lining,  whose  cells  have,  however,  undergone  proliferation  in  addi- 
tion to  cloudy  swelling,  and  granular  and  mucoid  degeneration  of 
the  cell  contents ;  these  latter  changes  often  render  the  cellular 
nature  of  the  layer  somewhat  less  obvious  on  account  of  the 
obliteration  of  the  cell  outlines,  especially  in  unstained  sections. 

Beneath  the  epithelial  there  is  usually  a  deeper  layer,  composed 
of  a  network  of  irregularly  interlacing  fibrillae,  resembling  coagu- 
lated fibrin,  and  enclosinsf  leu- 


cocytes in  its  meshes:  this 
fibrinous  material  often  extends 
into  the  ducts  of  the  glands.  In 
a  recently  formed  patch  beneath 
this  deep  layer  will  generally  be 
found  a  fairly  normal  Ddsemc^nt 
membrane  ;  occasionally,  how- 
ever, the  lowermost  layers  of 
the  original  stratified  epithelium 
will  be  seen  interposing  be- 
tween the  fibrinous  layer  and 
the  basement  membrane.  In" 
some  older  patches,  and  more 
particularly  in  those  around 
which  the  hyperemia  is  of  higb 
grade,  the  deeper  mucous  and 
sub-mucous  structures  present 
various  degrees  of  inflammation- 
with  engorged  vessels,  and  the 
infiltration  of  the  tissues  with 
leucocytes.  In  the  worst  and 
Fig.  CXXXiu.-PosT-MORTK.M  ArrEAR-  ^lost  advanced  cases  of  false 

ANCEOF  rHROAT,LARYNX,ANUTRACHEA 

AFFECTED  WITH  DIPHTHERIA  (OPENED  membrauc  of  thc  pharynx, 
FROM  BEHIND).  whcthcr  duc  to  diphtheria  or 

V.  Posterior  surface  of    E.  Epiglottis.  ,  -  ,^r^^ 

velum  palati.  v.c.  Vocp.l  cords.  as  the  result  of  artificial  or 
T.  Tonsils.  TR.  Trachea.  accidental  induction,  the  infil- 

tration and  exudation  of  fibrinous  serum  leads  to  blocking,  then 
to  degeneration  and  necrosis  of  the  circumferential  vessels, 
ending  in  the  formation  of  a  sequestrum  or  slough.  The 
inflammatory  process  does  not  always  stop  at  the  submucosa, 
but  may  extend  to  the  whole  depth  of  the  tissues,  involving  even 
the  muscular  structures  of  the  larynx.  Sometimes  these  various 
stages  are  to  be  detected  in  different  parts  of  the  same  throat  ; 


DIPHTHERIA. 


347 


the  colour  and  appearance  of  any  particular  patch  enablin<^  us 
roughly  to  form  an  opinion  of  its  age,  depth,  character,  etc. 
Fig.  CXXXIIL,  which  is  also  reproduced  in  colour  as  Fig.  117  on 
Plate  XIV.,  well  illustrates  the  naked-eye  appearances  of  the 
exudation  at  different  situations.  The  specimen  was  taken  from  a 
child,  aged  4  years. 

Renshaw's  experiments  point  to  the  fact  that  there  is  probably 
some  relation  between  the  age  and  the  colour  of  the  membrane 
and  its  relative  contagiousness ;  it  is  possible  that  this  may  be  in 
some  way  connected  with  the  stage  of  germination  of  the  vegetable 
organisms,  and  perhaps  with  the  later  production  of  poisonous 
ptomaines  and  albumins. 

Symptoms  :  A.  Functional. — Diphtheria  is  in  most  cases 
ushered  in  by  general  constitutional  symptoms  after  a  variable 
incubation  period  of  from  one  to  three  or  four  days  ;  exceptionally 
it  may  be  limited  to  a  few  hours,  or  prolonged  to  a  week  or  more, 
and  the  interval  has  been  extended  by  some  authors  to  even 
three  or  four  weeks.  The  invasion  is  usually  gradual  in  adults 
and  older  children,  but  may  be  quite  sudden  in  infants  ;  it  is 
rarely  marked  by  rij^ors  in  children,  as  mentioned  by  Schech,  for 
such  a  circumstance  is  as  unusual  in  this  as  in  any  other  disease 
of  childhood  ;  but  prodromal  syrnptoms  of  malaise  are  quickly 
followed  by  a  certain  amount  of  pyrexia,  with  headache,  drowsi- 
ness, thirst,  vomiting,  and  diarrhoea  ;  at  the  same  time  there  is 
often  stiff  neck,  pain  at  the  angle  of  the  jaw,  and  more  or  less 
sore  throat.  About  this  time  erythematous  cutaneous  eruptions 
occasionally  make  their  appearance,  and  often  obscure  the 
diagnosis.  Within  a  few  hours  of  these  first  symptoms  of  fever, 
or  exceptionally  after  a  longer  time,  the  special  local  manifesta- 
tions in  the  pharynx  become  obvious,  as  evidenced  by  pain  in  the 
throat,  especially  on  swallowing,  and  a  feeling  of  dryness  and 
desire  to  hawk  and  clear  the  fauces.  The  voice  is  distinctly 
rough  and  hoarse  even  before  there  is  membrane  in  the  larynx, 
but  when  this  has  spread  to  that  situation  the  hoarseness  is  much 
increased,  and  in  some  instances  all  vocal  tone  is  lost ;  there  is 
also  a  laryngeal  cough,  noisy  stridor,  and  dyspnoea,  due  to 
obstruction,  with  paroxysmal  exacerbations  of  true  spasm. 

Laryngeal  symptoms— should  the  disease  spread  downwards- 
set  in  from  the  third  to  the  eighth  day,  and  are  invariably  ushered 
in  by  a  rise  of  temperature,  which  is  often  considerable,  and  some- 
times by  vomiting.  In  laryngo-tracheal  diphtheria  of  children, 
the  noisy,  whistling,  stertorous  breathing,  and  other  indications 
of  obstructed  respiration,  make  their  appearance  early;  there  is 


348 


Diseases  of  the  throat  and  nose. 


sinking  in  of  the  lower  part  of  the  thorax,  the  larynx  is  drawn 
down  during  inspiration,  and  the  accessory  muscles  of  respiration 
come  into  play.  As  the  chink  of  the  glottis  gets  narrowed  by  the 
increase  in  area  and  in  thickness  of  the  deposit,  the  choking  and 
asphyxiating  paroxysms  will  become  frequent ;  the  little  patient, 
after  exhibiting  more  and  more  restlessness,  will  throw  its  arms 
about  and  clutch  at  the  throat.  The  period  of  commencing  cyanosis, 
which  follows,  is  one  of  comparative  repose,  and  is  accompanied 
by  cold  sweats,  blueness  of  the  ears  and  extremities,  and  a  fall  of 
temperature.  The  gradually  increasing  carbonic  acid  poisoning 
produces  first  apathy,  then  somnolence,  later  coma,  and  finally 
death  in  from  twelve  to  thirty  hours.  In  adults,  for  obvious 
anatomical  reasons,  a  circumscribed  patch  in  the  larynx  rarely 
causes  dyspnoea  ;  in  such  cases,  however,  extension  downwards 
may  take  place,  leading  to  bronchitis  and  lobular  pneumonia,  with 
later  symptoms  somewhat  resembling  those  above  described. 

When  the  nose  is  implicated,  its  normal  functions  are  interfered 
with,  and  fluids  often  escape  during  swallowing,  from  the  palatal 
muscles  being  affected ;  there  is  nasal  discharge  of  a  peculiarly 
fetid  and  sanious  character,  and  sometimes  epistaxis,  this  latter 
being  a  very  grave  symptom. 

In  the  most  malignant  forms  of  diphtheria  the  symptoms  often 
assume  an  asthenic  or  typhoid  character  from  the  beginning. 
Such  cases  sometimes  die  quite  suddenly ;  in  others  the  patient 
is  attacked  by  unexpected  and  oppressive  palpitation,  to  be  fol- 
lowed by  great  prostration,  cyanosis,  and  death  in  a  fev/  hours. 
The  pathology  of  such  is  probably  very  varied,  but  they  are  often 
associated  with  either  thrombosis  of  the  ventricle  and  pulmonary 
artery,  or  with  acute  inflammation  and  fatty  degeneration,  and 
possibly  with  microbic  invasion,  of  the  heart-muscle  ;  or  with  a 
paretic  condition  of  the  cardiac  nerves;  this  last  being  due  to  the 
action  of  toxic  products. 

If  the  stomach  and  intestines  are  involved,  corresponding  local 
symptoms  will  be  observed.  The  lesion  is  usually  found  to  arise 
in  Peyer's  patches — the  intestinal  tonsi/s,  in  fact. 

A  case  of  diphtheric  enteritis  came  under  my  observation  in  the  year  1SS4.  The 
patient,  a  general  practitioner,  was  attacked  with  all  the  symptoms  of  intestinal  obstruction 
whilst  actively  engaged  in  attending  a  large  number  of  cases  of  epidemic  diphtheria  ; 
marked  asthenia  was  exhibited  early  in  the  disease,  and  the  illness  terminated  in  death 
from  perforation  and  faecal  escape  into  the  peritoneai  cavity.  At  the  post-mortem  examina- 
tion several  diphtheritic  patches  and  ulcers  were  found  in  the  small  and  large  intestines. 
The  real  nature  of  the  case  was  quite  unsuspected  till  the  autopsy  revealed  it. 

During  the  epidemic  of  diphtheria  at  Ealing  in  1887,  two  cases  came  under  my 
notice  of  sisters  who,  with  others,  were  attacked  in  a  school.  One  had,  in  common 
with  other  pupils,  pharyngo-laryngeal  diphtheria  from  which  she  recovered  ;  the  other  had 
no  throat  symptoms,  but  died  of  perforative  peritonitis— the  result  of  diphtheritic  enteritis. 


DIPHTHERIA. 


349 


Some  perversion  of  function  of  the  special  senses  of  smell, 
taste,  and  hearing  will  generally  be  found  if  carefully  looked  for. 
The  odour  of  the  breath  is  always  tainted,  and  in  malignant  cases 
is  so  extremely  offensive  that  no  caution  is  needed  to  be  given  to 
the  attendants  to  be  careful  not  to  inhale  it.  The  progressive 
paralyses  we  shall  allude  to  under  the  head  of  Sequelae. 

B.  Physical  Signs. — These  have  mostly  been  either  already 
described  under  Pathology,  or  incidentally  alluded  to  under  the 
preceding  heading.    A  brief  recapitulation  will  suffice  here. 

Pharynx  (Fig.  42,  Plate  V.). — The  fauces,  at  first  red,  will  soon 
become  the  seat  of  exudation  patches,  which  can  be  observed  to 
increase  in  thickness,  to  become  tougher  in  consistence,  and  to 
extend,  sometimes  quite  rapidly,  in  area.  Their  colour,  from  a 
pellucid  white  or  hoar-frost  appearance,  will  gradually  assume  a 
yellow,  dirty  brown,  grey,  and  greyish-black  hue.  The  yellowish 
chamois-leather  colour  is  often  first  formed  at  the  edge  of  the 
patch.  If  exfoliation  takes  place,  or  if  the  pseudo-membrane  is 
artificially  removed,  either  a  slightly  eroded  granular  surface,  or 
else  a  raw  and  hsemorrhagic  one,  is  seen.  This  condition,  how- 
ever, soon  gives  place  to  a  fresh  exudation.  Even  when  patches 
do  not  exist  on  the  palate,  it  will  be  observed  to  be  changed  in 
colour,  which  varies  from  a  livid  purple  to  a  dusky  grey  tinge.  In 
many  of  these  cases  use  of  the  rhinal  mirror  will  reveal  patches  on 
the  posterior  surface  of  the  soft  palate  and  uvula.  The  fact  of  an 
exudation  on  the  uvula,  and  especially  on  its  posterior  surface,  is 
regarded  by  me  as  a  point  of  almost  pathognomonic  importance. 
If  the  naso-pharynx  is  much  blocked  by  adenoids,  the  gravity  of 
the  prognosis  will  be  increased  ;  but  it  may  be  modified  by  adop- 
tion of  operative  measures,  for  subsequent  formation  or  re-deposit 
of  membrane  is  not  worse  than  post-nasal  stenosis  during  an  attack. 

Examination  of  the  nose  (Fig.  43,  Plate  V.),  after  a  post-nasal 
douche  of  warm-water,  will  usually  exhibit  much  the  same  sur- 
face conditions  of  colour.  If  there  are  distinct  patches  on  the 
nasal  mucous  membrane,  they  will  probably  be  present  on  the 
superior  surface  of  the  palate ;  also  the  palatal  muscles  will  be 
early  paralyzed  in  those  cases  in  which  there  is  both  anterior  and 
posterior  palatal  exudation,  this  same  palsy  explaining  the  regur- 
gitation of  fluids  through  the  nares,  so  common  when  the  nose  is 
implicated  by  the  exudation.  The  discharge  from  the  nostrils  in 
nasal  diphtheria  is  peculiarly  offensive  and  irritating  to  the  skin, 
which,  by  contact  round  the  alse  and  upper  lip,  becomes  in- 
flamed, raw  and  eczematous.  Patches  of  membrane  may  also  be 
exceptionally  seen  on  the  inside  of  the  cheeks  or  lips,  and  on  the 
conjunctiva. 


350 


DISEASES  OF  THE  THROAT  AND  NOSE. 


If  the  larynx  (Fig.  55,  Plate  VI.),  is  implicated  tlie  fact  is 
usually  rendered  evident  by  the  synriptoms  previously  enumerated, 
as  well  as  by  portions  of  membrane  being  coughed  up ;  these  ex- 
pectorated fragments  are  often  of  considerable  size,  and  some- 
times form  complete  casts  of  the  parts  from  which  they  have 
become  detached.  Only  a  satisfactory  laryngoscopic  examination, 
however,  can  give  us  an  adequate  idea  of  the  extent  of  surface 
involved.  I  cannot  recall,  as  a  matter  of  fact,  that  there  is  any 
special  portion  of  the  larynx  more  prone  than  another  to  the 
membranous  exudation,  though  in  all  probability  the  same  law 
which  obtains  with  regard  to  the  greater  liability  to  other  forms 
of  inflammation  of  those  portions  in  which  the  mucous  membrane 
is  loosely  attached,  would  hold  good  in  the  case  of  diphtheria. 

C.  Miscellaneous. — In  addition  to  the  foregoing  signs,  func- 
tional and  physical,  all  other  symptoms  point  to  the  presence  of 
a  disease  of  an  extremely  depressing  nature. 

Although  presenting  all  the  surface  indications  characteristic  of 
an  infectious  fever,  there  is  nothing  very  distinctive  of  diphtheria 
in  the  tongue  ;  it  is  foul  and  loaded  from  the  first,  and  in  un- 
favourable circumstances,  as  the  disease  advances,  is  harsh  and 
dry  and  covered  with  thick  dark  fur. 

The  pulse,  rapid  from  the  commencement,  is  small  and  feeble  ; 
in  this  respect  differing  from  that  of  croup.  Intermission  in  the 
beat  will  indicate  cardiac  failure,  and  diminution  in  frequency 
below  the  normal,  with  a  corresponding  decrease  of  power,  will 
be  noticed  when  death  is  approaching  from  general  exhaustion. 
It  is  also  to  be  remembered  that  depression  of  the  pulse  during 
inspiration  is  a  sign  of  laryngeal  stenosis.  One  of  the  first  signs 
of  recovery  will  be  diminution  in  frequency  and  gain  in  volume. 

The  thermometer  gives  indications  of  the  first  importance  in 
diphtheria,  and  there  are  few  diseases  in  which  it  affords  greater 
aid,  albeit  the  variations  are  not  always  very  extreme.  As  a  rule, 
an  increase  may  be  taken  to  point  to  a  further  extension  or 
complication,  and  reduction  within  certain  limits  is  usually  a  sign 
of  improvement.  Commencing  with  a  more  or  less  rapid  rise  to 
102°  or  103°  F.,  the  temperature  is  immediately  lowered  on 
appearance  of  false  membrane  on  the  phar3mx,  and  may  become 
even  subnormal.  Then,  at  a  period  varying  from  the  third  to  the 
sixth  day,  there  will  again  be  a  rise.  This  gives  intimation  either 
that  the  larynx  is  becoming  involved,  or,  other  things  being  favour- 
able, may  be  due  to  occurrence  of  suppuration  at  the  base  of  the 
pharyngeal  exudations  prior  to  their  separation.  A  further  rise 
may  give  warning  of  a  nephritis  or  pneumonia,  while  a  serious 


DIPHTHERIA. 


fall  at  this  sta^e  below  the  normal  will  be  an  unfailing  evidence  of 
decrease  of  vital  power,  and  will  prognosticate  death  by  asthenia. 

In  very  young  children,  sudden  rises  in  the  temperature  are  not 
always. indicative  of  such  grave  changes  as  in  the  case  of  adults, 
which  circumstance  agrees  with  our  thermometric  experience  in 
other  infantile  maladies. 

Enlarged  glands  in  the  neighb'^urhood  of  the  throat  and  neck, 
especially  at  the  angle  of  the  jaw,  will  nearly  always  be  found. 
The  parotid  aud  submaxillary  are  sometimes  the  seat  of  consider- 
able inflammation. 

Auscultation  of  the  heart  and  lungs,  which  should  be  made  at 
least  once  daily,  since  by  such  means  only  is  early  warning  of 
thoracic  complications  to  be  ensured.  In  a  case  to  be  presently 
narrated,  Cheyne-Stokes  respiration  was  probably  due  to  nasal 
obstruction,  and  not  to  organic  mischief. 

A  physical  and  chemical  examination  of  the  urine  should  never 
be  omitted,  albumen,  casts  and  blood  being  especially  sought  for. 
Uraemic  symptom.s  occasionally  occur,  more  especially  in  young 
children  when  the  nephritis  is  severe.  Nausea,  continued  vomit- 
ing, loss  of  appetite,  frequent  pulse,  drowsiness,  somnolence,, 
occasionally  eclampsia,  coma  and  cardiac  failure,  clearly  indicate 
the  onset  of  this  grave  complication.  The  only  thing  with  which 
it  is  likely  to  be  confounded  at  an  early  stage  is  commencing 
septicaemia,  but  the  thermometer  will  aid  in  settling  this  "question. 

Varieties  of  Diphtheria. — -^Wagner,  --Jenner  and  others, 
have  described  different  forms  of  diphtheria  ;  with  all  deference  to 
such  eminent  authorities,  I  cannot  admit  that  such  classifications 
are  either  logical  or  satisfactory,  whether  made  on  anatomical  or 
on  clinical  grounds,  or  on  a  consideration  of  both  together :  for  at 
no  period  during  the  course  of  any  so-called  variety  can  it  be 
prognosticated  that  it  will  not  later  assum.e  the  characters  of  some 
ether  form.  Thus,  as  in  other  specific  fevers,  the  symptoms  are 
sometimes  so  mild  that  the  disease  escapes  recognition.  This  is 
the  diphtheritic  sore  throat  and  tonsillitis  which  is  usually  met 
with  during  epidemics  in  adults  attending  on  cases  of  diphtheria, 
and  is  sometimes  considered  as  catarrhal.  There  may  be  little 
pyrexia,  and  that  of  short  duration,  and  no  albuminuria  ;  in  some 
instances  there  may  be  no  sequelae ;  in  others  these  will  be  well 
marked,  and  will  give  the  first  indications  of  the  nature  of  the 
disease.  Cases  of  this  kind  will  be  recalled  to  the  memory  of  every 
practitioner.  On  the  other  hand,  a  case  commencing  as  a  mild 
one  may  take  on  a  highly  inflammatory  and  malignant  type,  with 
hyperpyrexia  and  excessive  exudation,  the  disease  running  to  a 


352  DISEASES  OF  THE  THROAT  AA^D  NOSE, 

quickly  fatal  issue  ;  or  the  symptoms  may  assume  a  low,  asthenic 
form  from  the  commencement,  and  ultimately  typhoid  symptoms 
may  set  in. 

Complications  and  Sequels. — An  ordinary  case  of  diphtheria 
lasts  from  a  few  days  to  a  fortnight  or  more,  but  complications 
may  very  much  prolong  the  duration  of  the  attack.  The  chief 
amongst  these  are  alarming  and  often  fatal  cardiac  failure,  acute 
pulmonary  diseases,  excessive  albuminuria,  and  haemorrhages 
from  the  nose,  pharynx,  air-passages,  and  other  parts.  Asthenia^ 
anaemia,  and  slight  albuminuria  may  last  a  considerable  time. 

Of  all  the  sequelae  the  most  interesting  are  the  paralyses 
due  to  progressive  parenchymatous  degeneration  of  the  peri- 
pheral motor  and  sensory  nerves.  Paresis  or  paralysis  of 
motion  and  sensation  of  the  soft  palate  is  usually  the  first 
symptom.  Loss  of  ocular  accommodation  from  implication  of 
the  ciliary  muscle  quickly  follows.  The  tongue,  lips,  and  cheeks 
are  then  generally  involved,  the  paralysis  extending  even  to  the 
pharyngeal  muscles.  Still  later  the  muscles  of  the  extremities 
and  of  the  trunk  suffer.  Peculiar  sensations  of  tingling  and 
numbness  indicate  commencing  implications  of  the  limbs. 

It  frequently  happens  that  whilst  parts  supplied  by  one  set  of 
nerves  are  becoming  functionless,  others  previously  attacked  are 
progressing  towards  recovery. 

This  was  well  exemplified  in  a  case  which  was  brought  to  my  notice  of  a  child  who  had 
first,  diaphragmatic  paralysis  along  with  paresis  of  the  upper  extremities  from  implicatioa 
of  the  cervical  nerves  ;  later  on  intercostal  breathing  became  impaired,  but  by  this  time 
the  diaphragm  had  resumed  work. 

Differential  Diagnosis. — Epidemic  diphtheria  is  easily  re- 
cognisable. The  pharyngeal  patches  may  be  confounded  with 
aphtha  or  herpes,  with  simple  membranous  inflammation,  whether 
idiopathic  or  traumatic,  with  exudative  lacunar  tonsillitis,  with 
syphilis,  with  phlegmonous  pharyngitis  due  to  erysipelas  or  septic 
causes,  with  scarlatina  and  other  constitutional  fevers.  The 
crucial  test  is  the  presence  of  the  bacillus ;  but  failing  bacterio- 
logical investigation,  the  history  and  subsequent  rapid  progress  of 
the  case,  the  temperature  chart  and  the  condition  of  the  urine, 
will  clear  up  the  diagnosis.  The  thermometer  is  here  of  the 
greatest  value.  The  temperature  is  usually  high  in  tonsillitis,  but 
it  rapidly  falls,  especially  in  the  rheumatic  variety,  on  the  appear- 
ance of  the  lacunar  exudation  or  on  formation  of  pus.  Many  a 
case  of  diphtheria  is  at  its  commencement  diagnosed  as  a  ton- 
sillitis ;  possibly  the  opposite  may  also  occasionally  occur  ;  and  it 
is  worthy  of  remark  that  in  addition  to  the  test  of  the  thermo- 


DIPHTHERIA. 


353 


meter,  the  great  pain  and  difficulty  in  opening  the  mouth  so 
characteristic  of  the  milder  malady  will  materially  assist  to  a 
correct  recognition  of  the  nature  of  the  case.  In  scarlet  fever  the 
temperature  is  always  high,  103°  to  105"  F.,  and  remains  so  for 
some  days.  In  diphtheria  the  thermometer  rarely  records  a 
higher  temperature  than  101°  or  102°,  and  never  a  continuously 
high  one ;  but,  as  already  stated,  it  is  characterized  rather  by  a 
series  of  elevations  and  depressions  coincident  with  extension  of 
the  disease  and  fresh  complications. 

The  physical  test  par  excellence  is  that  whereas  the  so-called 
exudation  of  lacunar  tonsillitis  can  be  easily  brushed  away  with- 
out denudation  of  the  epithelium,  in  diphtheria  some  force  is 
required  for  removal  of  the  membrane,  and  a  bleeding  surface, 
indicating  invasion  of  the  mucous  membrane,  is  exposed. 
In  mycosis  tonsillaris  I  have  occasionally  seen  small  hsemorrhagic 
points  after  detachments  of  the  fungoid  growth  ;  quite  different, 
however,  from  the  raw  surface  of  diphtheria,  and  with  appropriate 
treatment  there  is  no  re-deposit. 

With  aphtha  and  herpes,  diphtheria  will  rarely  be  confounded 
even  by  the  tyro  after  the  second  visit.  As  to  membranous  sore 
throat,  apart  from  membranous  laryngitis  I  do  not  recognise  such 
a  disease  uncomplicated  by  specific  influences  of  constitution  or 
hygiene.  In  pharyngeal  erysipelas,  which  includes  the  septic  sore 
throat  of  some  authors,  the  temperature  is  higher  ;  there  is  always 
great  distress  ;  the  tissues  are  very  cedematous  and  livid,  and  the 
cutaneous  surface  of  the  neck  is  usually  also  involved. 

In  its  anatomical  seat,  essential  histological  structure,  and  in 
some  of  its  clinical  characters,  laryn go -tracheal  diphtheria  presents 
a  remarkable  resemblance  to  membranous  croup  ;  so  much  so,  that 
many  specialists  regard  the  two  diseases  as  identical.  In  the 
former  editions  of  this  work  I  combated  this  view  at  some  length. 
Further  experience  and  observation  have  only  tended  to  strengthen 
the  opinion  I  have  always  held,  namely,  that  the  membranous 
croup  of  children  is  a  non-specific  disease  of  the  larynx  and 
trachea,  bearing  a  close  relationship  to  cedematous  laryngitis  of 
adults,  but  etiologically  and  in  some  points  clinically  distinct  from 
the  highly  infectious  and  specific  malady,  diphtheria,  which  very 
rarely  originates  in  the  larynx  or  trachea,  and  may  terminate 
fatally  without  extension  to  those  parts.  The  analogy  between 
the  two  diseases  is  much  the  same  as  that  between  enteritis  and 
enteric  fever,  ordinary  pneumonia  and  the  septic  or  typhoid 
variety,  local  traumatic  erysipelas  and  the  malignant  infectious 
form.     Membranous  croup  is  sporadic  and  non-inoculable  ;  it 

23 


354 


DISEASES  OF  THE  THROAT  AND  NOSE. 


attacks  children,  rarely  youths,  and  never  adults.  It  is  not 
infectious ;  the  exudation  is  the  essential  feature  in  causing 
death  by  mechanical  obstruction.  The  glandular  swelling  in  the 
neck,  so  universal  in  diphtheria,  is  not  present  in  the  non-specific 
disease.  It  is  sthenic  rather  than  asthenic  in  its  features.  The 
pulse  is  hard  and  strong  in  most  cases.  In  croup  the  urine  rarely 
contains  albumen,  and  paralytic  sequelae  are  absent.  Lowering 
remedies  are  well  borne.  Attention  to  these  facts  will  usually 
enable  one  to  diagnose  between  a  case  of  membranous  laryngitis 
which  is  characterized  by  the  foregoing  symptoms,  and  a  solitary 
case  of  laryngo-tracheal  diphtheria. 

The  -^Scientific  Committee  appointed  by  the  Royal  Medico- 
Chirurgical  Society  to  inquire  into  the  relations  of  membranous 
croup  and  diphtheria,  collected  a  mass  of  highly  interesting  matter, 
embracing  hospital  statistics  and  the  private  records  and  opinions 
of  general  physicians  and  practitioners.  The  main  conclusions 
arrived  at  by  the  Committee  were  that  '  membranous  affection 
of  the  larynx  may  arise  in  connection  with  common  inflammation 
or  with  specific  disorders  of  several  kinds,  the  most  common  of 
which  in  this  relation  is  that  which  produces  similar  change  else- 
where, and  which  is  recognised  as  diphtheria.  In  the  larger 
number  of  cases  of  membranous  affection  of  the  larynx  the  cause 
is  obscure  {i.e.,  in  any  given  case  it  is  difficult  to  predicate  the 
particular  cause  in  that  case).  Amongst  those  in  which  it  is 
apparent,  common  irritation  seldom  presents  itself  as  a  source  of 
the  disease  ;  accidental  injury  is  but  very  infrequent!}/ productive  of 
it.  But  few  cases  of  undoubted  origin  from  exposure  to  cold  are 
on  record.  On  the  other  hand,  in  a  very  large  number  of  cases 
infective  or  zymotic  influence  is  to  be  traced.'  I  have  quoted  the 
exact  words  of  this  Report,  because,  notwithstanding  the  fact  that 
the  Committee  were  evidently  in  favour  of  considering  laryngo- 
tracheal diphtheria  and  membranous  laryngitis  as  identical,  careful 
perusal  of  the  whole  document  brings  out  very  strongly  the  fact 
that  a  large  majority  of  those  who  contributed  to  the  investigation 
by  answering  the  Committee's  circular  of  questions,  were  so  clear 
in  their  opinion  that  non-specific  membranous  laryngitis  exists 
(and  is  fairly  frequently  met  with  in  practice)  as  quite  a  distinct 
disease  from  primary  laryngo-tracheal  diphtheria,  that  it  was 
impossible  for  the  Committee  to  speak  more  definitely.  The 
experiments  of  24Baginsky,  since  substantiated  by  -^Ruault,gc 
far  to  settle  this  question.  This  observer  contends  that  there 
are  two  forms  of  membranous  exudation  with  similar  clinical 
symptoms  :  the  first,  malignant  and  often  fatal,  in  which  bacilli 
are  found ;  the  second,  comparatively  benign,  in  which  only  cocci 


DIPHTHERIA. 


355 


can  be  found.  Loeffler,  as  weli  as  Roux  and  Yersin,  had  pre- 
viously described  2i  pseudo-bacillus  of  diphtheria. 

Prognosis,  Course,  and  Termination. — The  forecast  of  diph- 
theria must  always  be  very  grave,  and  though  undoubtedly  many 
recoveries  take  place,  complications  are  so  numerous  and  serious 
that  it  is  almost  impossible  to  predict  a  successful  issue  from  any 
case,  however  mild  at  its  commencement,  until  restoration  to 
health  is  so  far  advanced  that  the  practitioner  feels  he  can  dismiss 
the  patient  from  his  care.  When  death  results  it  may  occur 
within  twelve  hours  of  the  first  manifestation  of  membrane  in  the 
larynx,  and,  according  to  Jenner,  is  never  delayed  beyond  the 
fifth  day  from  that  event.  Between  such  an  early  termination, 
due  to  laryngeal  extension,  the  time  at  which  the  fatal  issue  may 
take  place  varies  from  one  to  five  or  six  weeks.  After  tracheotomy 
the  same  uncertainty  prevails,  and  death  may  occur  by  a  sudden 
attack  of  cardiac  or  respiratory  failure  even  when  all  appears  to  be 
going  well.  As  in  croup,  age  is  a  very  important  element  in  the 
formation  of  prognosis,  and  the  younger  the  patient  the  less  likely 
is  the  issue  to  be  favourable.  The  course  of  the  case  towards  re- 
covery or  death  will  depend  more  or  less  on  the  following  points : 
The  character  of  the  epidemic  and  hygienic  surroundings  already- 
detailed  in  our  remarks  on  etiology  ;  the  site  and  amount  of  deposit 
— whenever  the  nose,  larynx,  or  intestines  are  involved,  the  issue  is 
always  grave ;  aural  pain  due  to  extension  from  the  throat  to  the 
middle  ear,  and  great  pain  in  the  throat  from  glandular  enlarge- 
ment, are  also  symptoms  of  unfavourable  significance.  Obstruc- 
tions to  respiration  in  the  nose,  naso-pharynx,  and  fauces  from  ton- 
sillar enlargements  are  factors  of  the  gravest  danger.  Ecchymoses, 
epistaxis  and  other  hsemorrhages,  and  purpuric  spots,  likewise 
indicate  serious  complications.  Asthenia  and  cardiac  failure, 
typhoid,  septicsemic,  ursemic,  or  other  low  constitutional  states, 
render  the  chance  of  recovery  doubtful. 

It  cannot  too  strongly  be  enforced  that  the  condition  of  the  renal 
secretion  should  also  be  carefully  watched  for  the  presence  of 
excessive  albumen,  casts,  and  blood,  because  on  the  knowledge 
gained  by  such  examination  our  judgment  as  to  the  course  will 
be  materially  influenced.  Suppression  of  urine  is  a  precursor  of  a 
fatal  issue.  Persistent  anorexia,  vomiting,  and  diarrhoea  tend  to 
lower  the  patient  and  endanger  life ;  and  these  symptoms  may  be 
present  in  a  marked  degree  without  the  intestines  being  attacked  by 
deposit.  When  this  latter  condition  exists  there  is  usually  constipa- 
tion, with  vomiting,  which  after  a  time  becomes  faecal.  The  gravity 
of  lung  complications  will  depend  not  only  on  the  nature  of  the 
pulmonary  disease  and  amount  of  tissue  involved,  but  also  on  the 
condition  of  the  larynx  and  general  state  of  the  patient. 


356 


DISEASES  OF  THE  THROAT  AND  NOSE. 


There  is  no  necessity  to  recapitulate  the  various  modes  in  which 
death  may  be  brought  about.  Suffice  it  to  say  that  all  those  pri- 
mary causes  which  are  enumerated  in  our  remarks  on  croup  equally 
apply  to  this  disease ;  and,  in  addition,  there  is  fear  of  the  many 
secondary  complications  which  we  have  repeatedly  indicated. 
Recovery  after  tracheotomy  is  naturally  much  less  certain  when 
performed  for  diphtheria  than  for  the  non-specific  inflammation. 
When  the  tendency  is  to  recovery  there  is  a  gradual  abatement  of 
the  functional  symptoms,  of  which  the  temperature  and  especially 
the  pulse  are  the  first  to  give  indication  of  improvement.  Re- 
spiration and  articulation  will  next  be  favourably  affected  as  the 
membrane  is  separated  and  the  inflammation  subsides.  Relief  of 
pain  in  the  neck  and  throat  general^  will  also  be  experienced  as  the 
glandular  enlargement  is  lessened  ;  but  the  difficulty  of  swallowing 
may  become  even  worse  rather  than  better,  as  ulcers  are  exposed  on 
separation  of  the  membrane,  or  when,  as  not  unfrequently  occurs^ 
paralytic  sequelae  follow  closely  on  the  acute  attack.  This  last 
circumstance  may  also  give  rise  to  characteristic  and  increased 
impairment  of  the  voice.  These  nervous  sequelae  usually  termi- 
nate favourably,  but  much  will  depend  on  the  extent  and  site 
of  the  paralyses.  Exceptionally  the  whole  constitution  of  the 
patient  may  be  undermined  to  such  a  degree  that  for  the  re- 
mainder of  life  the  effect  of  an  attack  will  from  time  to  time  be 
manifested.  In  others  it  may  be  years  before  the  baneful  influence 
is  finally  eradicated. 

Recurrence. — One  attack  of  diphtheria,  like  erysipelas,  is 
generally  believed  not  to  protect  against  a  second,  and  is  even 
held  by  many  to  predispose  tow^ards  the  latter,  -^acobi  actually 
thinks  that  patients  during  convalescence  are  sometimes  re- 
infected, but  then  he  considers  that  man}^  of  the  cases  of  so- 
called  follicular  tonsillitis  and  *  herpetic  angina '  of  the  French 
are  nothing  but  diphtheria.  I  cannot  personally  recall  a 
single  instance  of  well-authenticated  recurrence,  but  since  these 
views  in  favour  of  second  attacks  are  held  by  observers  of  high 
authority,  I  give  them  precedence  to  the  negative  evidence  of  m}- 
own  experience. 

Treatment. — Prescriptions  for  both  constitutional  and  local 
measures  for  the  cure  of  diphtheria  have  been  even  more  varied 
and  more  numerous  than  the  views  which  have  from  time  to  timt^ 
prevailed  as  to  the  character  of  the  systemic  disorder — believed 
by  some  to  be  the  cause,  b}'  others  the  result,  of  the  diphtheritic 
contagium. 

Their  very  variet}'  and  multiplicity,  not  to  sa}-  their  frequently 


DIPHTHERIA. 


357 


mutual  incompatibility,  have  only  served  to  show  how  unstable 
and  unsatisfactory — even  up  to  the  present  day — are  the  scientific 
foundations  of  the  therapeutics  of  this  disease  ;  for  hardly  a  week 
passes  without  '  bold  advertisement '  of  a  new,  general,  or  topical 
specific  for  diphtheria. 

Since  it  would  be  manifestly  impossible  in  the  limits  of  this 
treatise  to  discuss  the  merits  of  all,  I  propose  to  pass  in  review 
the  most  noteworthy  and  more  generally  accepted  remedial 
measures,  not  hesitating  to  state  plainly  objections  where  I  differ 
from  the  views  of  others,  however  established  their  authority,  nor 
to  indicate  with  equal  directness  what  is  my  own  practice  when 
called  upon  to  advise  in  any  of  the  various  contingencies  of  an 
ordinary  or  an  extreme  case. 

Remedies  for  this  disease,  as  for  all  others,  require  to  be  con- 
sidered as  (i)  Internal  or  general ;  (2)  Local ;  (3)  Dietetic ; 
(4)  Operative ;  and  (5)  Hygienic  and  prophylactic.  Each  of 
these  main  divisions  is  capable  of  being  discussed  under  several 
sub-headings,  as  will  presently  appear. 

I.  Of  general  or  internal  remedies  of  the  nature  of  drugs,  it 
is  probable  that  none  are  of  really  more  special  use  in  diphtheria 
than  are  those  advised  for  any  other  acute  infectious  disorder ; 
and  while  many  practitioners  pin  their  faith  to  one  remedy,  or 
one  combination  of  remedies,  others  consider  it  more  rational 
in  theory,  and  more  satisfactory  in  practice,  to  administer  to 
symptoms  as  they  may  arise,  having  always  in  view  the  para- 
mount necessity  for  recuperative  measures. 

Of  one  thing  I  am.  assured — namely,  that  when  an  author 
states  that  this  or  that  remedy  is  a  specific,  and  that  he  has  never 
lost  a  case,  the  diagnosis  has  been  frequently  faulty.  I  have  often 
been  placed  in  the  difficult  position  of  having  to  point  out  to  a 
medical  man,  who  had  called  me  in  consultation  to  a  supposed 
case  of  diphtheria,  that  the  disease  under  consideration  was  really 
either  lacunar  tonsillitis,  mycosis  tonsillaris,  or  septic  sore  throat, 
and  it  is  more  than  probable  that  many  cases  reported  as  instances 
of  recurrent  diphtheria  have  been  of  this  nature. 

Probably  few  practitioners  would  nowadays  give  mercury  to 
salivation,  or  submit  a  patient  to  systematic  mercurial  inunction  ; 
but  there  is  much  to  be  said  in  favour  of  the  administration  of  one 
or  more  moderate  doses  of  calomel  and  James's  powder.  And 
Jenner's  practice  to  commence  with  a  purge  commends  itself  to 
all,  except  those  modern  pharmacologists  who  ignore  the  import- 
ance of  clear  primcB  vice. 

Treatment  by  emetics,  whether  as  mild  as  alum  or  ipecacuanha, 


v358 


DISEASES  OF  THE  THROAT  AND  NOSE. 


or  as  energetic  as  antimony,  zinc,  copper,  or  apo-morphia,  is  a 
course  not  to  be  recommended,  and  except  in  the  very  earliest 
stages  must  be  unconditionally  condemned,  though  no  less 
eminent  a  physician  than  ^/"Fagge  advises  that  '  when  diphtheria 
attacks  the  larynx,  the  treatment  must  be  exactly  such  as  would 
be  employed  in  the  more  advanced  stages  of  croup.  An  emetic 
of  ipecacuanha  or  of  sulphate  of  copper  should  be  given ;  and  if 
a  good  result  is  obtained,  it  may  be  repeated  at  an  interval  of 
some  hours.' 

Independently  of  the  belief  that  the  amount  of  assistance  given 
by  emetics  in  the  release  of  laryngeal  exudation  is  somewhat 
exaggerated,  I  cannot,  looking  to  the  general  asthenic  nature 
of  diphtheria,  assent  to  their  use  at  so  late  a  period  as  that  of 
laryngeal  extension.  It  has,  moreover,  been  conclusively  shown 
that  forcible  separation  of  the  membrane — unless  the  denuded 
surface  be  immediately  medicated  with  a  germicide — is  a  harmful 
proceeding,  because  not  only  is  the  membrane  re-formed,  but  be- 
cause thereby  the  micrococci — which,  in  point  of  fact,  develop  on 
the  most  superficial  layers  of  the  membrane — are  enabled  to  pass 
readily  through  the  irritated  and  bleeding  surfaces  into  the  blood- 
vessels and  deeper  tissues.  It  is  for  this  same  reason  that  external 
blisters  are  contra-indicated. 

On  account  of  the  danger  of  depressant  drugs,  I  would  not 
advise  either  internal  or  hypodermic  administration  of  pilocarpine 
or  other  agent  which  should  produce  profuse  diaphoresis  at  any 
stage,  as  has  been  practised,  and  with  report  of  good  results,  by 
several  Continental  practitioners.  ^^Oertel  especially  recommends 
pilocarpine  in  the  belief  that  it  hastens  separation  through  *  the 
mechanical  raising  of  the  membranes  by  exciting  increased 
secretion  of  mucus.'  He  administers  from  o*oi  to  0*05  gramme 
of  pilocarpinum  miiriaticum  dissolved  in  water,  either  at  one  time 
or  at  short  intervals  ;  or  in  adults,  especially  when  the  morbid 
process  has  existed  already  several  days,  he  makes  subcutaneous 
injection  of  from  O'ooi  to  0'002  gramme. 

While  having  but  little  experience  of  the  efficiency  of  expectorants, 
I  venture  to  think  they  are  prescribed  on  an  entirely  false  concep- 
tion of  the  nature  of  the  malady;  and  though  I  have  read  of  the 
administration  of  chloride  of  ammonium,  of  senega,  and  of  san- 
guinaria,  I  have  not  yet  met  the  practitioner  who  considers  that 
these  remedies  are  of  special  or  material  service  in  the  disease 
under  consideration. 

Cubebs  and  copaiba,  which  would  also  come  under  the  head  of 
expectorants,  were  first  recommended  as  specifics  ten  years  ago 


DIPHTHERIA. 


359 


by  "'Trideau,  who  prescribed  them  in  very  large  doses.  They  are 
also  advocated  by  Beverley  Robinson,  and  other  competent 
practitioners ;  but  of  their  utility  in  diphtheria  I  am  unable  to 
personally  testify. 

Of  other  specifics,  the  majority  have  been  given  for  their 
f^ermicide  or  antiseptic  action  ;  and  of  this  class  those  most  in 
repute  have  been  the  sulpho-carbolates  recommended  by  ^^San- 
som,  sulphites  of  soda  and  potassium,  carbolic  acid,  salicylic  acid 
and  the  salicylates,  and  the  chlorates  and  benzoates  of  potash  and 
soda,  some  of  the  latter  acting  also  as  antipyretics.  "^^Fontaine 
has  given  sulphide  of  calcium  with  the  view  of  destroying  the 
germs  and  splitting  up  the  toxic  alkaloids  by  means  of  the 
generation  in  the  stomach  of  sulphuretted  hydrogen.  Probably 
with  the  intent  of  converting  these  alkaloids  into  insoluble  com- 
pounds with  mercury,  the  bin-iodide  has  lately  been  advocated  by 
'*'^Stepp,  and  is  much  employed  by  others.  It  probably  acts  in  the 
same  way  as  in  syphilis.  Iodide  of  potassium  is  also  advised,  for 
the  purpose  of  introduction  of  the  iodine  into  *  the  blood  and 
other  Hquid  elements,  and  into  glands,  where  it  amalgamates 
with  albuminoid  molecules,  and  possibly  with  the  bacteria  ;  in  any 
case,  it  sterihzes  media  in  which  bacteria  develop.'  Of  remedies 
likewise  considered  specific  and  acting  variously,  according  to 
the  views  of  their  advocates,  as  germicides,  as  alteratives,  and  even 
as  ionics,  are  minute  doses  of  the  bi-cyanide  and  perchloride 
of  mercury  and  quinine.  Of  tonics,  recuperatives,  and  analeptics 
may  also  be  mentioned  quinine,  iron,  strychnia,  and  cinchona. 

Probably  the  internal  treatment  almost  universally  held  in 
favour  by  modern  practitioners,  is  a  combination  of  the  antiseptic 
or  antipyretic  with  tonics.  Chlorate  of  potash  with  perchloride 
of  iron  heads  the  list  in  general  esteem,  though  the  former  is  to 
be  given  with  caution  in  view  of  its  power  to  aggravate  a  tendency 
to  nephritis. 

Personally,  I  do  not  largely  prescribe  iron  or  quinine  in  the 
early  stages  of  diphtheria,  since  I  have  thought  there  is  frequently 
a  difficulty  in  their  assimilation,  and  especially  of  the  large  doses 
in  which  iron  is  prescribed.  Further,  all  who  have  experience 
with  regard  to  iron  in  this  disease  will  agree  with  ^^Rose-Cormack 
that  though  it  has  '  a  decidedly  beneficial  action  under  certain 
circumstances,  it  neither  arrests  nor  modifies  the  character  of  the 
malady  in  its  early  and  most  perilous  stages  ;  but  its  utility  is 
unquestionable  as  an  adjuvant,  when  in  the  natural  course  of 
the  disease  a  spontaneous  curative  tendency  has  begun  to  manifest 
itself.' 


360 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Being  an  adherent  of  the  view  that  micro-organisms  are  not 
the  only  factors  in  contagious  processes,  and  holding  that  the 
virus  is  quite  as  much  a  chemical  one,  and  for  the  most  part  of 
an  albuminoid  constitution,  my  treatment  naturally  aims  at : 

I.  By  internal  remedies  aiding  the  system  in  the  elimination  of 
the  chemical  virus  by  the  ordinary  excretory  channels — skin,  bowels, 
kidneys,  lungs,  etc. 

II.  Directly  attacking  the  chemical  virus  circulating  in  the 
blood  by  bringing  about  such  a  chemical  decomposition  as  will 
split  up  the  toxic  products  into  less  poisonous  compounds. 

III.  Combating  the  poisonous  effects  of  the  virus  on  the  system 
by  treating  fever,  cardiac  depression,  and  other  constitutional 
symptoms  as  they  arise. 

IV.  Annihilating  micro-organisms  by  germicides  locally  and 
systemically  administered. 

V.  Sustaining  the  vital  powers  by  appropriate  diet,  including 
ozonic,  oxygenated,  and  germicidal  drinks. 

VI.  Adopting  such  mechanical  and  operative  treatment  as  will 
enable  the  patient  to  breathe  freely  and  to  swallow  nutriment. 

VII.  Artificially  modifying  the  atmospheric  conditions  of  the 
sick-room  to  meet  the  needs  of  each  individual  case. 

VIII.  Adopting  appropriate  prophylactic  and  hygienic  measures. 
Proceeding  to  details,  after  the  purge  before  recommended,  or 

one  or  two  doses  of  the  mercurial  and  antimonial  alterative,  I  used 
to  begin  with  a  mixture  (Form.  g8)  containing  remedies  in  com- 
bination, with  a  threefold  intention — namely,  by  means  of  salicy- 
late of  soda,  I  strove  to  reduce  general  pyrexia  and  local 
inflammation ;  to  this  was  added  chlorate  of  sodium,  for  the 
purpose  of  generating  oxygen  without  depression ;  and  lastly 
these  were  administered  in  a  medium  of  decoction  of  cinchona, 
Vv^hich  has  not  only  a  certain  germicidal  action,  but  constitutes  a 
tonic  more  easily  assimilated  than  in  its  alkaloidal  form  as  quinine. 
The  soda  salts  are  always  to  be  preferred  to  those  of  potash  in 
this  and  all  diseases  manifesting  symptoms  of  depression ;  the 
salicylate  is  to  be  given  in  very  moderate  doses,  and  must  be 
omitted  should  there  be  any  symptom  of  cardiac  complica- 
tion. I  only  resorted  to  more  powerful  tonics  such  as  iron  in 
the  later  possible  eventuality  of  symptoms  of  extensive  systemic 
infection,  depression,  and  exhaustion.  Such  a  treatment  was  often 
sufficient  for  mild  cases,  and,  so  far  as  the  pyrexia  is  concerned, 
the  value  of  salicylic  acid  in  alkaline  solutions,  or  of  antipyrin 
and  antifebrin,  is  not  to  be  ignored ;  but  the  almost  irresistible 
evidence  in  favour  of  the  view  that  diphtheria,  though  in  the  first 


DIPHTHERIA. 


.361 


instance  a  local  disease,  is  speedily  associated  with  the  presence 
of  poisonous  albnmoses  in  the  system,  indicates  the  administration 
of  a  drug  that  shall  form  insoluble  and  therefore  inert  chemical 
compounds  with  these  toxic  agents.  This  we  possess  in  biniodide 
of  mercury,  which  should  be  given  in  adult  doses  of  xV  to  J  of  a 
grain;  in  young  children  of  one  year  old  and  upwards  I  give 
to  iV  of  a  grain,  according  to  age.  I  prefer  the  smaller 
doses,  frequently  repeated,  and  I  am  in  the  habit  of  combining  a 
minute  quantity  of  ipecacuanha.  Probably  the  success  which  has 
attended  the  treatment  of  diphtheria  by  cyanide  of  mercury,  so 
long  in  vogue  with  the  homoeopaths,  can  be  explained  by  a  similar 
action  on  the  toxines. 

There  is  doubtless  quite  as  much  harm  effected  by  the  undue 
pushing  of  analeptic  and  stimulant  remedies  at  early  stages  as  in 
the  opposite  plan  of  depressing  by  drugs,  which  promote  profuse 
emesis  or  diaphoresis;  and  what  is  said  here  as  to  drugs  will 
equally  apply  to  alcohol.  While  its  use  is  not  advised  in  the 
early  stages,  it  is  not  to  be  withheld  or  stinted  whenever  the 
pulse  gives  indications  of  cardiac  enfeeblement. 

It  would  be  travelling  too  far  beyond  the  realm  of  the  specialist 
to  enter  into  the  treatment  of  each  possible  complication  ;  but  a 
word  or  two  may  be  said  on  that  of  paralytic  sequelcB. 

For  these  conditions  the  phosphates  of  iron,  quinine,  and 
strychnia  should  be  administered  perseveringly ;  and  so  soon  as 
there  is  reduction  of  inflammation,  electricity  either  in  the 
induced  or  constant  form,  as  indicated  by  the  reactions,  is  to  be 
employed.  Strychnia  has  been  advantageously  employed  by  me 
hypodermically  in  cases  not  yielding  to  electrical  measures.  Fric- 
tion and  massage,  with  hot  and  cold  douches,  are  also  of  service. 

2.  Local  remedies  for  diphtheria  are  even  m.ore  numerous  than 
the  constitutional,  and  the  local  treatment  of  this  disease  was  the 
first  subject  selected  for  discussion  in  the  sub-section  of  laryngology 
at  the  meeting  of  the  International  Medical  Congress  in  London 
in  1881.  Whether  diphtheria  be  or  be  not  considered  as  a 
primarily  local  affection,  there  can  be  no  doubt  that  much  of 
its  danger  depends  on  the  localization  of  the  lesion  in  the  throat ; 
and  the  importance  of  efficient  topical  measures  m.ust  therefore  be 
recognised  to  the  fullest  extent. 

Local  remedies  are  to  be  divided  into  internal  and  external. 
Of  the  former,  solvents  of  the  membrane  come  first  on  the  fist,  and 
to  this  form  of  treatment  I  have  given  much  attention,  and  have 
made  repeated  experiments  with  some  of  the  different  fluids  which 
have  from  time  to  time  been  recommended.    As  a  result,  I  have 


362  DISEASES  OF  THE  THROAT  AND  NOSE. 

found  that  though  no  chemical  agent  possesses  the  property  of 
effecting  any  actual  solution  of  the  membrane,  an  alteration  in  its 
character  does  appear  to  ensue.  Membrane  macerated  in  pure  lactic 
acid,  undiluted,  became  soft,  translucent,  and  jelly-like.  Pieces 
of  exudation  from  the  same  subject  similarly  treated  in  lime-water 
were  rendered  more  friable,  but  no  thinner ;  and  this  molecular 
change  was  more  perceptible  with  saccharated  lime-water.  The 
solutions  were  raised  to  boiling-heat,  and  lowered  to  freezing- 
point  ;  but  the  experiments  were  not  affected  by  the  temperature 
of  the  fluid  employed.  Taking  into  consideration  the  fact  that 
one  cannot  apply  such  solutions  quite  undiluted  in  the  throat — 
that  one  cannot  exclude  air,  even  with  all  the  balsamic  applica- 
tion in  the  world,  especially  when  laid  over  a  moist  surface — that 
one  cannot  obtain  a  direct  temperature  influence  either  with 
steam  inhalation  or  by  sucking  ice  to  anything  like  the  degree 
that  was  obtained  in  these  experiments,  I  came  to  the  conclusion, 
fully  borne  out  by  my  clinical  experience,  that  these  fluids 
possess  no  solvent  properties  whatever,  but  that  lactic  acid,  not 
diluted  to  the  high  extent  hitherto  in  use,  but  applied  pure  by 
the  surgeon  at  least  once  or  twice  a  day,  and  only  moderately 
diluted — say  i  to  6 — every  two  or  three  hours  by  the  nurse,  has 
some  considerable  influence  in  loosening  the  molecular  cohesion 
of  its  particles  in  a  manner  more  favourable  to  separation  than 
lime  solutions,  which  appear  to  me  quite  valueless.  In  this  last 
opinion,  I  am  glad  to  have  the  support  of  so  high  an  authority 
as  ^^Tobold.  ^^Cohen  administers,  instead  of  lime-water,  in- 
halations of  the  former  from  lime  in  the  process  of  slacking 
every  second  hour,  hour,  or  half-hour;  and  if  that  does  not 
appear  to  suit  the  case,  he  substitutes  inhalations  of  the  warm 
spray  of  bromine  ;  and  these  faihng,  he  recommends  that  the 
sulphurous  acid  spray  should  be  tried.  Cohen  does  not  assert 
that  the  lime  acts  chemicall}^  on  the  membranes,  and  thinks  it 
merely  wedges  them  up  mechanically  here  and  there,  permitting 
better  access  of  the  aqueous  vapour  ;  but  that  it  acts  beneficially 
in  forcing  the  expulsion  of  shreds  of  membrane,  casts,  and  the 
like,  he  has  no  doubt.  It  is  only  right  to  add  that  he  admits 
that  *this  treatment  is  likely  to  induce  capillar}'  bronchitis,  or 
even  pneumonia  ....  but  that  is  a  secondary  matter  to  be 
attended  to  subsequently.'  Of  other  applications  having  repute 
as  solvents,  may  be  mentioned  the  tincture  of.perchloride  of  iron, 
solutions  of  chloral  hydrate  and  carbolic  acid,  papaine,  and  resorcin. 
As  to  iron,  Cohen  draws  attention  to  the  fact  that  '  aqueous 
solutions  of  iron  are  not  as  useful  as  the  tincture  j  and  this 


DIPHTHERIA. 


363 


leads  to  the  inquiry  whether  its  local  action  n:iay  be  in  any 
measure  due  to  the  alcohol,'  by  its  destructive  action  on  the 
bacteria,  and,  it  may  be  added,  b}^  shrivelling  and  detaching  the 
membrane  through  abstraction  of  the  elements  of  water  ;  but  it 
is  now  clearly  understood  that  alcohol  possesses  no  germicidal 
properties  whatever.  It  arrests  development  of  germ^,  but  does 
not  destroy  them.  It  is  possible  also  that  the  free  hydrochloric 
acid  contained  may  have  a  beneficial  action,  since  this  agent  was 
at  one  time  held  in  repute  as  a  caustic  and  solvent,  and  is  even 
still  employed.  Lastly,  the  iron  itself  may  act  constitutionally 
as  well  as  locally.  But  I  have  satisfied  myself  by  experiment 
that  membrane  macerated  in  the  iron  tincture  undergoes  no 
disintegrating  change,  but  is  rather  toughened  than  otherwise 
by  such  a  proeedure.  With  regard  to  chloral^  which  is  highly 
esteemed  by  my  former  teacher,  Mr.  Hughes  Hemming,  of  Kim- 
bolton,  its  value  in  allaying  convulsive  and  asthmatic  conditions 
generally,  renders  it  probable  that  this  drug  also  acts  generally  as 
well  as  locally.  The  same  may  be  said  of  carbolic  acid,  which 
has  no  solvent  action  on  diphtheritic  membrane  when  employed 
experimentally  on  removed  portions.  As  a  germicide,  carbolic 
acid  and  the  carbolates  occupy  a  much  lower  position  in  the 
scale  than  was  formerly  ascribed  to  them.  Sidphurous  acid  has 
given  good  results,  and  is  indicated  for  the  twofold  reason  that  it 
is  an  efficient  germicide,  and  that  it  acts  both  systemically  as 
well  as  locally.  Papaine  and  resorcin  are  said  to  act  very  efficiently 
as  solvents  ;  but  experiments  that  I  have  made  lead  me  to  think 
that  their  solvent  action  is  but  feeble.  The  preparation  of  papaine 
that  I  have  used  has  been  that  of  Finckler,  but  quite  lately  the 
result  of  a  trial  with  Christy's  papaine  inclines  me  to  hope  for 
more  satisfactory  results. 

^^Oertel,  likewise  a  firm  believer  in  the  local  and  parasitic  origin 
of  diphtheria,  considers  that  '  we  possess  in  carbolic  acid,  though 
not  a  specific,  yet  a  most  efficient  remedy.  To  produce  its  anti- 
septic and  antiparasitic  effect,  we  must  employ  more  concentrated 
solutions  than  have  been  used  heretofore.'  He  recommends  *  for 
local  action  on  diphtherial  mucous  membranes  5  per  cent, 
solutions,  nebulized  by  means  of  a  steam  apparatus,  and  inhaled 
by  the  patient  every  two  or  three  hours,  and  even  oftener,  for 
from  two  to  five  minutes,  according  to  the  severity  of  the  case 
and  the  age  of  the  patient.' 

I  am  quite  in  accord  with  those  who  consider  that  caustics 
are  harmful— chiefly  because  of  their  liability  to  injure  con- 
tiguous healthy  tissue  —  though  ^^Bloebaum  of  Coblentz  has 


3^4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


reported  successful  results  from  galvano-caustic  applications, 
made  in  the  belief  that  they  destroy  micro-organisms,  which, 
with  probable  correctness,  he  holds  to  be  the  primary  cause  of  the 
disease.  I  agree  also  with  those  who  think  that  mere  astringents 
are  useless.  The  chlorides  and  sulphates  of  zinc,  alum,  etc.,  have  no 
germicidal  or  solvent  action  of  sufficient  potency.  Alkaline  solu- 
tions, as  of  bicarbonate  of  potash  or  soda,  are  advocated  by  Schech 
as  solvents.  As  such  they  have  no  power,  but  they  doubtless 
neutralize  the  acid  poisons  generated  by  the  life-processes  of  the 
micro-organisms. 

Truth  to  say,  I  am  so  well  satisfied  with  lactic  acid  that  I  have 
been  loth  to  try  any  other  local  remedy.  I  may  add  that  I  have 
not  found  it  injurious  to  contiguous  healthy  tissues,  that  is  to  say, 
wherever  the  epithelial  layer  is  entire.  In  this  respect,  it  is  pre- 
ferable to  hydrochloric  acid,  while  it  is  even  more  efficacious  as  a 
digester,  so  to  speak,  of  the  diseased  membrane.  I  have  all  the 
stronger  conviction  that  lactic  acid  is  destined  to  become  a  valuable 
local  remedy  in  diphtheria,  from  its  great  efficacy  in  faucial  and 
laryngeal  tuberculosis,  and  in  lupus.  Its  action  appears  to  be 
limited  almost  solely  to  unhealthy  tissue  ;  there  is,  it  is  true,  some 
circumferential  inflammation,  but  as  this  leads  to  the  outpouring  of 
scavenging  leucocytes,  it  can  only  be  regarded  as  a  desirable  result. 

Coming  to  the  best  method  of  removing  the  membrane,  or  at 
least  of  applying  the  solution,  it  has  been  generally  taught  that 
tearing  away,  or  scraping  off,  the  exudation  is  as  useless  and 
injurious  a  proceeding  as  would  be  similar  treatment  of  the 
pustules  of  small-pox,  and  is  even  dangerous,  for  the  reason  that 
it  leads  to  more  thorough  systemic  infection ;  but  a  diphtheritic 
patch  is  probably  more  comparable  to  a  chancre  of  syphilis  than 
to  an  exanthematous  rash.  I  have  always  myself  practised  some 
degree  of  friction  of  the  diseased  surface  with  a  soft  but  firm  appli- 
cator well  charged  with  the  lactic  acid  solution,  and  I  have  been 
better  satisfied  with  the  results  when  I  have  more  or  less  detached 
the  membrane.  For  this  purpose,  in  the  case  of  children  I  employ 
and  instruct  the  nurse  to  use  the  index-finger  well  swathed  with 
lint  and  soaked  in  the  solution  ;  and  for  adults  an  aluminium, 
whalebone  or  vulcanite  rod  with  a  firm  head  of  absorbent  wool. 

'^^Nix  of  Rude,  Denmark,  who  was  reported  at  the  Congress  in 
1 88 1  to  have  had  great  success  with  free  use  of  lunar  caustic  after 
removal  of  the  false  membranes,  has  recently  again  urged  the 
radical  treatment  of  scraping  them  away  daily  with  a  sharp  spoon. 
In  the  belief  that  the  disease  is  purely  local,  this  physician  thus 
aims  at  extirpating  the  soil  in  which  the  diphtheria  is  growing. 


DIPHTHERIA.  \  365 


Watson  Cheyne,  who  also  considers  diphtheria  2.3  *  from. first 
to  last  a  local  disease^  the  general  symptoms  being'  merely  due  to 
chemical  poisoning,'  advises  '  stripping  off  the  false  membrane 
with  forceps,  etc.,  as  far  as  possible,  and  then  applying  a  watery 
solution  of  bichloride  of  mercury,  [so  strong  as]  i  in  500.'  He 
also  urges  frequent  gargling  with  a  weaker  solution,  i  in  2,000 — 
all  this  being  combined  with  carbolic  acid  sprays.  Early  trache- 
otomy is  advocated,  and  similar  treatment  of  the  lower  air- 
passages  through  the  tracheal  opening. 

Whilst  I  cannot  advocate  the  application  of  caustics  for  the 
slow  removal  of  false  membrane  as  advised  previously  by  Nix, 
and  again  quite  recently  by  ^^May,  I  believe  the  time  will  soon 
come  when  Watson  Cheyne's  surgical  procedure  will  be  acknow- 
ledged generally  to  be  as  efficient  as  it  is  scientific.  The  means 
of  removal,  whether  sponge,  probang,  forceps,  or  vulsellum,  is  un- 
important so  long  as  removal  is  thoroughly  performed.  If  after 
detachment  of  membrane  a  mercurial  application  be  preferred  to 
that  of  lactic  acid,  the  biniodide,  as  a  non-precipitator  of  serum- 
albumen,  would  appear  to  possess  advantages  over  the  bichloride. 
It  can  be  used  in  the  form  of  either  spray,  pigment  or  mouth-wash, 
and  in  a  strength  of  i  in  2,000  to  1,000. 

I  regret  to  say  that  I  cannot  speak  except  in  terms  of  dis- 
agreement with  ^^lorell-Mackenzie's  recommendation  to  apply 
varnishes  to  the  throat  of  a  patient,  whether  of  tender  or  mature 
years,  who  may  be  suffering  from  diphtheria  ;  for  however  per- 
sistently blotting-paper  be  previously  applied,  as  advised  by  him, 
it  is  impossible  to  have  a  sufficiently  dry  surface  for  cohesion  of  a 
varnish,  more  especially  since  this  author  is  also  a  strong  advocate 
of  hyper-saturation  with  steam  of  the  atmosphere  immediately 
surrounding  the  patient.  But  the  treatment  is  open  to  still  more 
serious  objection,  whether  considered  from  the  point  of  view  of 
the  nature  of  the  diphtheritic  contagium,  or  of  the  danger  of  the 
exudation  in  the  throat  as  a  mechanical  obstruction  to  respiration. 
Even  if  cohesion  of  the  varnish  took  place,  it  is  doubtful  if  it 
would  prevent  development  of  the  germs,  and  it  certainly  would 
not  kill  them  ;  while  in  relation  to  ptomaines,  and  other  chemical 
poisons,  exclusion  of  air  is  highly  undesirable.  Lastly,  the  bal- 
samic application  is  only  so  much  more  local  hindrance  to  free 
respiration. 

As  to  steam,  I  have  to  repeat  what  I  have  said  in  speaking  of 
croup,  that  I  am  not  an  advocate  for  its  use  to  the  amount 
recommended  by  many,  because  I  have  often  witnessed  great 
7ital  depression  induced  by  its  persistent  or  extravagant  employ- 


linr-iApY 


366 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ment.  The  indications  for  this  measure  will  be  modified  not 
only  by  the  amount  of  catarrhal  inflammation  present,  but  also 
by  the  time  of  the  year,  and  other  surrounding  atmospheric  con- 
ditions.   Of  course,  steam  is  always  employed  after  tracheotomy. 

Oertel  recommends  six  or  eight  direct  inhalations  of  hot  steam 
a  day  intercurrently  with  the  carbolic  spray  previously  mentioned ; 
he  advocates  employment  of  moist  heat  in  this  form,  because  it 
'  promotes  suppuration,  and  thereby  demarcation  and  separation 
of  the  membranes.'  If  steam  is  employed  in  this  way,  I  would 
greatly  prefer  to  evaporate  with  it  menthol,  Sanitas  or  Eucalyptus 
solutions. 

In  the  so-called  mild  cases,  especially  those  of  suspected  diph- 
theritic sore  throat,  and  especially  in  patients  above  the  age  of 
infancy,  benefit  would  be  derived  from  the  wearing  of  an  oro- 
nasal  inhaler,  containing  oxidizing  and  anodyne  properties 
(Form.  41),  a  small  portion  to  be  sprinkled  on  the  v/ool  or 
sponge  of  the  inhaler.  After  tracheotomy,  covering  of  the  tube 
with  corrosive  sublimate  gauze  would  be  useful,  and  the  inhalant 
just  named  could  be  administered  by  placing  a  few  drops  from 
time  to  time  on  the  gauze. 

I  cannot  but  think  that  gargles,  and  the  like,  do  often  but 
weary  the  patient ;  but  wherever  the  nostrils  are  obstructed,  or 
are  the  seat  of  membrane — and  in  the  comparatively  few 
autopsies  of  patients  with  faucial  diphtheria  that  I  have  made, 
such  has  always  been  the  case — syringing  or  spraying  of  the 
nares  with  the  biniodide  solution,  followed  by  application  of 
lactic  acid,  is  of  the  highest  value.  In  cases  of  diphtheria  in 
which,  without  extension  of  disease  to  the  nares,  there  is  impeded 
nasal  respiration — and  in  children  this  is  very  frequently  the  case 
— I  am  in  the  habit  of  spraying  the  nostrils  with  a  10  per  cent, 
solution  of  menthol  in  oil,  or  of  applying  an  ointment  of  menthol 
in  vaseline,  and  of  similar  strength,  by  means  of  a  small  brush. 
No  trouble  must  be  spared  to  keep  the  nasal  choanae  patent. 

Externally,  hot  applications  to  the  throat  in  the  way  of  poultices 
are  cumbersome,  wearisome,  and,  in  my  experience,  unproductive 
of  sufficient  relief  to  compensate  for  their  inconvenience.  In  my 
papex  at  the  Congress  in  1881, 1  made  tentative  recommendations 
of  Leitcrs  coils  for  application  of  continuous  cold  in  place  of  ice- 
bags  ;  and  since  that  time  I  have  had  oft-repeated  testimony,  in 
my  own  practice  and  that  of  friends  and  colleagues,  of  their  great 
value  in  diphtheria  as  a  means  of  applying  constant  cold  without 
moisture.  The  effect  is  to  reduce  inflammation,  and  to  favour 
rapid  necrosis  and  separation  of  the  exudation.  In  my  experience 


DIPHTHERIA. 


367 


these  results  are  thus  obtained  more  successfully  without  the  depres- 
sion of  the  steam  inhalations  of  Oertel.  There  is,  however,  nothing 
to  prevent  the  concurrent  adoption  of  both  these  measures. 

3.  Dietetic  treatment  is  placed  next  in  order  for  consideration, 
because  by  means  of  food,  medication,  both  internal  and  topical, 
can  be  largely  supplemented.  A  diabetic  diet  is  theoretically  indi- 
cated in  all  microbic  diseases.  There  cannot  be  a  doubt,  I  suppose, 
in  the  minds  of  anyone  as  to  the  value  of  ice  taken  by  the  mouth 
as  a  grateful,  refreshing,  and  efficient  means  of  reducing  hyperaemia, 
and  of  aiding  to  dissolution  of  the  exudation.  Seeing  the  difficulty 
of  making  children  take  ice,  I  am  in  the  habit  of  giving  them  it  in 
the  form  of  frozen  milk  sweetened  with  saccharin,  or  sugar  of  milk, 
or  of  frozen  beef-tea.  I  recommend  the  same  in  the  case  of  adult 
patients,  and  advise  them  to  take  but  little  other  nourishment  by 
the  mouth  except  the  raw  egg  swallowed  whole,  such  as  I  have 
recommended  for  other  diseases  in  which  the  function  of  degluti- 
tion, being  painful  and  difficult,  requires  to  be  rested,  or  performed 
with  the  least  possible  effort.  Regarding  this  question  of  functional 
rest,  wherever  there  is  a  likelihood  of  the  case  becoming  a  severe 
one,  and  especially  if  food  by  the  mouth  becomes  distasteful, 
regular  administration  of  nutrient  enemata,  at  an  early  period  of 
the  disease,  should  be  adopted. 

One  more  measure,  which  has  a  topical  as  well  as  a  general 
effect,  is  the  free  administration  of  barley-water  flavoured  with 
lemon,  or  even  better  still  is  fresh  lemonade,  either  of  them 
being  largely  impregnated  with  chlorate  of  sodium.  Frequently, 
excepting  a  calomel  purge  or  the  administration  of  a  small 
amount  of  compound  antimonial  powder  at  the  commencement, 
I  give  no  other  medicine  in  the  early  stages.  Fontaine,  acting 
on  the  principle  that  germs  cannot  exist  in  acid  secretions,  makes 
a  strong  point  of  ordering  gargles  and  drinks  of  citric  acid.  Milk 
may  be  given  almost  ad  libitum,  to  be  diluted,  if  necessary,  with 
lime  or  soda  water,  or  with  hyper-oxygenated  effervescing  water. 
I  have  not  found  milk  to  disagree  with  diphtheritic  patients,  as  is 
by  some  believed  to  be  the  case.  Alcohol  is  to  be  administered 
systematically  so  soon  as  the  strength  shows  the  least  sign  of 
flagging,  and  subcutaneous  injection  of  ether  may  avert  or 
counteract  cardiac  inadequacy. 

The  following  recent  cases  are  worthy  of  record,  as  illustrating 
many  of  the  points  which  I  have  insisted  on  in  this  chapter  : 

C.  B.,  aged  three  years,  a  son  of  a  well-to-do  tradesman,  had  his  tonsils  removed  with 
the  guillotine  on  September  nth,  1889,  in  a  special  hospital  ;  the  child,  after  operation, 
was  taken  home  by  his  mother  to  her  residence  in  the  Edgware  Road.    A  week  after 


366 


DISEASES  OF  THE  THROAT  AND  NOSE. 


operation  he  was  brought  back  to  the  hospital  in  a  condition  of  malaise,  with  deposit  o! 
what  was  thought  to  be  the  usual  whitish  slough  on  the  site  of  the  operation  wounds  , 
as  this  was  already  partly  detached  it  was  removed  by  the  surgeon  ;  but  no  fear  appears 
to  have  been  entertained  of  any  gravity  in  the  case.  V/ithin  a  week  (thirteen  days  after 
operation)  this  child  died  at  home,  and  the  family  doctor,  under  whose  charge  he  was, 
certified  that  the  cause  of  death  was  croup. 

Two  days  later,  September  27th,  L.  B,,  aged  eight  years,  an  elder  brother  of  the  de- 
ceased, complained  of  sore  throat  and  was  brought  to  me  by  the  mother.  I  found  a  well- 
marked  diphtheritic  patch  on  the  left  tonsil.  On  inquiry,  it  appeared  that  the  shop 
•jccupied  by  this  family  was  in  a  most  insanitary  condition.  Two  other  children  were 
juffering  from  enlarged  tonsils  and  adenoid  growths,  and  a  number  of  workpeople  and 
servants  in  the  house  had  complained  of  sore  throats  for  some  considerable  period.  It 
became  evident  that  the  first  child,  after  tonsillotomy,  had  returned  to  an  insanitary  en- 
vironment, and  in  those  circumstances  had  readily  contracted  diphtheria,  which  had 
proved  fatal  in  his  case  and  had  subsequently  infected  his  brother,  the  present  patient. 
I  have  elsewhere  insisted  that  a  child  with  an  open  wound  in  the  \\\xo'3X'\%{ca:teris  parilnis) 
more  likely  to  catch  diphtheria  and  scarlet  fever,  and  I  have  always  taught  and  as  far  as 
]5ossible  insisted  that  a  child  requiring  tonsillotomy  should,  after  operation,  be  kept  for  a 
week  in  a  hospital  or  nursing  home. 

The  treatment  successfully  adopted  in  the  case  of  L.  B.  was  on  the  lines  laid  down  in 
the  preceding  pages.  On  diagnosing  a  diphtheritic  patch  on  the  left  tonsil,  I  at  once 
removed  every  portion  of  it  and  rubbed  a  60  %  solution  of  lactic  acid  into  the  exposed 
raw  surface,  having  previously  satisfied  myself  that  there  was  none  present  elsewhere. 
As  both  tonsils  were  very  much  enlarged,  and  together  with  the  soft  palate  and  glands  at 
the  angle  of  the  jaw  much  inflamed,  I  ordered  a  Leiter's  continuous  cold  coil  to  be 
applied  outside  the  neck  to  the  neighbourhood  of  the  tonsils  and  larynx.  The  nasal  choanse, 
which  were  markedly  obstructed,  were  well  washed  out  with  a  detergent  collunarium,  and 
the  erectile  swelling  of  the  turbinals  reduced  by  a  menthol  paint  every  three  hours.  The 
proper  air-way,  although  very  stenotic  before  the  illness,  was  by  these  means  kept  fairly 
patent  during  the  attack.  I  placed  the  patient  under  the  care  of  Mr.  W.  Hill,  who 
carefully  watched  the  case,  I  meeting  him  occasionally  in  consultation.  This  gentleman 
was  energetic  in  at  once  removing  any  sign  of  pellicular  re-formation  by  means  of  a 
sjionge  probang  soaked  in  lactic  acid.  No  re-deposit  took  place  after  the  third  day,  but 
the  lactic  acid  swabbing,  and  the  menthol  applications  to  the  nostrils  were  continued  for 
a  week.    During  this  period  biniodide  of  mercury  with  bark  was  administered  internally. 

The  temperature,  which  stood  at  101°  at  the  first,  was  never  above  99°  during  the  ap- 
plication of  Leiter's  cold  coil.  The  urine  contained  a  little  albumen  for  seven  days,  but 
this  disappeared  on  the  eighth  day,  i.e.,  one  day  after  the  administration  of  iodide  of 
iron.  The  cardiac  symptoms,  apart  from  a  rapid  pulse  of  120,  were  not  serious  when 
the  patient  was  awake,  but  Cheyne-Stokes  respiration  was  observed  on  the  third,  fourth, 
and  fifth  nights  when  the  child  was  asleep.  This  symptom  only  occurred  apparently 
when  the  nasal  cavities  became  much  blocked,  and  did  not  recur  when  the  choana;  were 
assiduously  kept  clear  by  the  nurse  with  menthol  paint,  applied  every  two  or  three  hours 
during  the  night.  As  regards  diet,  the  only  point  that  calls  for  mention  was  the  fact  that 
Mr.  Hill  ordered  no  sugar  to  be  added  to  milk  puddings,  lemonade,  and  other  food,  on 
tlie  ground  that  sugar  favours  the  growth  and  multiplication  of  micro-organisms.  Saccharin 
was  substituted.  This  child  made  a  most  favourable  recovery,  and  up  to  the  time  of 
going  to  press  has  developed  no  symptoms  of  paralysis.  I  saw  him  as  recently  as  January 
in  the  present  year. 

4.  Operative  measures  are  generally  supposed  to  be  comprised 
in  the  one  procedure  of  tracheotomy ;  but  it  is  now  fully  ten 
years  since  I  first  proposed  and  adopted  the  removal  of  enlarged 
ionsih  and  cedematous  tivulce  during  the  acute  stage  of  diphtheria. 


DIPHTHERIA. 


369 


All  who  have  any  experience  of  the  disease  must  be  aware  not 
only  how  prone  are  the  subjects  of  enlarged  tonsils  to  succumb 
to  diphtheritic  influences,  but  also  to  what  a  serious  extent  the 
existence  of  such  a  condition  comphcates  matters,  and  imperils 
the  chances  of  recovery.  One  must  have  seen  over  and  over 
again  oral  and  nasal  respiration  each  hour  more  impeded  from 
this  cause,  and  for  the  same  reason  inspection  of  the  larynx  made 
impossible.  I  therefore  in  1878  removed  the  tonsils  of  a  child 
suffering  from  diphtheria  on  the  first  occasion  of  my  seeing  her. 
The  result  was  an  immediate  improvement  in  her  breathing : 
there  was  no  extension  of  the  disease  to  the  larynx;  the  membrane 
was  of  course  re-deposited  on  the  cut  surfaces,  but  it  ultimately 
cleared ;  the  child  had  several  sequelae  of  diphtheria,  but  finally 
made  a  very  good  recovery.  I  reported  the  case  in  detail,  and 
exhibited  the  patient  at  the  "^^Medical  Society  of  London.  Since 
that  time  I  have  had  similar  cases  with  an  equally  good  result, 
and  also  others  in  which  I  have  removed  from  adults  swollen  and 
oedematous  uvulae  during  the  acute  diphtheric  state.  I  was  quite 
prepared  to  hear  the  wisdom  of  this  practice  questioned ;  but 
however  starthng  the  procedure  may  at  first  sight  appear,  any 
objections  which  could  be  raised  against  it  are  theoretical  rather 
than  practical,  and  of  no  account  in  the  balance,  when  weighed 
against  its  advantages — first,  as  removing  an  impediment  to  the 
respiration ;  secondly,  as  tending  to  prevent  the  downward 
progress  of  the  exudation ;  and  thirdly,  as  an  early  substitute, 
or  means  of  averting  the  necessity  for,  the  more  dangerous 
measure  of  opening  the  windpipe.  The  treatment  has  since 
been  adopted  by  ^^Lefferts,  who  prefers  in  such  instances  to 
substitute  the  lesser  danger  of  re-deposit  for  the  greater  one  of 
the  dyspnoea.  The  same  remarks  hold  good  in  respect  to  the 
removal  of  adenoids  causing  great  naso-pharyngeal  obstruction. 

Tracheotomy  is  a  procedure  that  is  each  year  viewed  more 
favourably,  mainly  because  the  indications  for  its  performance  are 
becoming  better  appreciated,  and  practitioners  are  now  able  to 
assure  the  relatives  of  a  patient  that,  when  adopted  sufficiently 
early,  the  chances  of  success  are  much  greater  than  formerly. 
Most  of  the  indications  are  functional,  of  which  suppression  of 
voice,  increasing  dyspnoea,  stridor,  and  other  symptoms  of 
asphyxia,  and  especially  retrocession  of  the  chest  walls,  are  the 
principal  signs  warning  us  that  the  air-passages  are  becoming 
alarmingly  obstructed.  If  before  occurrences  of  these  signals 
of  distress  membrane  can  actually  be  seen  in  the  larynx  by  means 
of  the  mirror,  no  delay  should  be  allowed  to  occur,  and  the  advis- 

24 


370 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ability  of  opening  the  windpipe  should  be  promptly  urged.  I  am 
not  an  advocate  for  its  performance  where  the  chances  are  hope- 
lessly unfavourable,  because  knowledge  of  fatal  results  tends  to 
influence  parents  in  their  consent  under  circumstances  which  are 
favourable.  Nevertheless,  it  is  to  be  noted  that  in  many  cases  in 
which  death  occurs  after  tracheotomy,  the  end  is  much  more 
tranquil  than  would  otherwise  have  been  the  case.  I  speak  of  this 
operation  principally  with  regard  to  children,  in  whom  death  by 
mechanical  obstruction  is  much  more  frequent  than  in  adults.  In 
the  latter,  tracheotomy  it  less  successful  than  in  children.  But 
looking  to  the  great  value  of  fresh  air  in  destroying  germs,  and 
in  modifying  the  noxiousness  of  septic  alkaloids,  tracheotomy 
possesses  an  importance  beyond  that  of  relieving  a  mechanical 
asphyxia,  and  it  is  with  this  especial  view  that  I  advocate  its  early 
adoption — namely,  so  soon  as  membrane  is  formed  in  the  larynx 
or  trachea. 

This  is  not  the  place  to  go  into  details  as  to  the  operation. 
Doubtless  the  tracheal  opening  is  to  be  regarded  merely  as  a  pre- 
liminary to  adoption  of  measures  for  clearing  the  air-passages  of 
membranous  obstruction,  and  the  practitioner  must  not  neglect 
continuance  of  persevering  efforts  in  that  direction,  and  in  such 
local  medication  as  may  prevent  exudative  re-formations ;  but  I 
cannot  resist  commenting  in  terms  of  remonstrance  against  the 
view  of  one  author  on  this  subject,  who,  with  all  the  prominence 
of  large  capitals,  has  formulated  the  following  dictum  : 

'  The  presence  of  membrane  in  the  trachea  in  a  fatal  case  of 
membranous  laryngitis,  after  tracheotomy,  must  be  regarded  as 
evidence  of  the  want  of  due  care  on  the  part  of  the  surgeon  in 
charge,  as  much  as  would  the  presence  of  a  piece  of  gut  in  the 
inguinal  canal  after  herniotomy,  or  a  calculus  in  the  bladder  after 
the  operation  of  lithotomy.' 

Not  only  is  such  a  dictum  on  its  simple  assertion  capable  of 
involving  many  an  excellent  practitioner  in  serious  trouble  with 
litigious  relatives,  but  by  *  a  nice  derangement  of  epitaphs  '  the 
analogies  are  entirely  inapplicable  and  illogical. 

"With  regard  to  removal  of  the  membrane  through  the  tracheal 
opening,  attempts  to  this  end  by  oral  suction,  either  of  doctor  or 
parent,  ought  not  to  be  necessary  in  these  advanced  days  of 
mechanical  aids.  One  very  simple  instrument  for  the  purpose  is 
that  of  a  Siegel's  exhausting  syringe,  such  as  is  employed  in  aural 
practice,  with  a  strong  exhausting  soft  rubber  bag  to  effect  suction 
and  the  aural  end  adapted  to  the  mouth  of  the  tube  by  means  of 
a  piece  of  soft  rubber  tubing.    Another  is  a  modification  made 


DIPHTHERIA, 


371 


for  me  by  Messrs.  Krohne  and  Sesemann  of  the  aspirator,  known 
as  Coudereau's.  By  this  instrument  not  only  can  exudation  be 
extracted,  but  by  a  very  simple  contrivance,  familiar  to  all  who 
use  aspirators,  fresh  air,  or  hyper-oxygenated  air,  can  be  intro- 
duced into  the  lungs  almost  instantaneously  after  the  extraction. 
An  atmosphere  of  steam  is  more  necessary  after  tracheotomy 
than  before,  since  it  is  most  important  to  guard  against  the 
occurrence  of  fresh  inflammation  due  to  inspiration  of  insufficiently 
tempered  air  by  the  tube. 

One  other  hint,  hardly  necessary  to  experts.  In  removing 
membrane  through  a  tracheal  canula,  it  is  better  to  clear  it  b}^  the 
inner  tube;  so  that  in  case  that  passage  is -blocked,  freedom  can 
be  given  to  respiration  through  the  outer  canula.  A  double 
canula,  always  of  value  in  tracheotomy,  is  of  indispensable  im- 
portance in  cases  of  diphtheria. 

Intubation  of  the  larynx  is  a  method  of  procedure  for  relieving 
laryngeal  dyspnoea  by  introducing  a  tube  through  the  mouth,  and 
placing  it  in  the  larynx,  with  its  upper  end  below  the  epiglottis. 
Although  this  procedure  was  first  adopted  by  Bouchut  in  1858, 
the  credit  of  re-introducing  and  gradually  perfecting  the  method 
now  in  use  must  be  assigned  to  Dr.  Joseph  O'Dwyer,  of  New 
York,  who  commenced  his  experiments  in  intubation  in  1880. 

In  the  last  edition  of  this  work  I  stated  that  intubation  was  still 
on  its  trial,  and  I  mentioned  some  objections  which,  to  my  mind, 
rendered  it  doubtful  whether  intubation  could  ever  largely  super- 
sede tracheotomy.  Since  then  the  operation  has  been  performed 
extensively  in  America,  and  to  some  extent  in  this  country.  I 
had  the  opportunity  of  seeing  some  cases  at  Chicago,  under  the 
care  of  Dr.  Waxham,  and  I  have  since  had  some  encouraging 
experiences  of  the  operation  in  my  own  practice.  I  am  bound 
to  confess  that  my  former  objections  have  been  almost  entirely 
dissipated,  and  in  a  '^^Paper  which  I  read  at  the  meeting  of  the 
British  Medical  Association  at  Glasgow,  in  1S88,  I  stated  some- 
what fully  my  present  views  on  the  subject,  which  further  experi- 
ence has  confirmed. 

The  vast  difference  in  the  frequency  with  which  the  operation 
has  hitherto  been  performed  in  America  and  in  this  country,  is 
no  doubt  partly  due  to  the  greater  prevalence  of  diphtheria  in 
America,  owing  to  less  perfect  sanitary  arrangements.  I  think, 
however,  that  it  is  probable  that  the  laryngeal  mirror,  not  having 
been  used  in  the  majorit}^  of  cases,  for  the  purpose  of  forming  an 
exact  diagnosis  of  the  condition  of  things,  the  operation  may  have 
sometimes  been  performed  for  mere  spasm,  and  before  membrane 


372 


DISEASES  OF  THE  THROAT  AND  NOSE. 


iiad  extended  to  the  glottis.  In  any  case,  it  is  unquestionable 
that  some  of  those  who  have  had  the  largest  number  of  cases  of 
intubation  in  America,  are  not  laryngologists,  nor  expert  with  the 
laryngoscope.  On  the  other  hand,  a  large  number  of  cases  have 
been  recorded  by  Roe,  Ingalls,  Casselbury,  Stern,  and  Bleyer,  tc 
the  nature  of  whose  cases  such  an  objection  could  not  possibly  be 
advanced. 

A  set  of  intubation  intruments,  as  now^  generally  sold,  consists 


I 


Fig.  CXXV.  a. — Intubation  Instruments. 


of  five  laryngeal  tubes,  together  with  a  gag,  an  introducer  and  an 
extractor  (Fig.  CXXV.  a).  A  scale  is  also  supplied  indicating  the 
length  of  the  tube  suitable  for  a  particular  age.  The  tubes  are 
made  of  brass  plated  with  gold,  and  vary  in  length  from  if  to  2 J 
inches.  The  calibre  of  the  largest  tube  is  about  J  by  J  inch,  and 
that  of  the  smallest  about  half  that  size.  The  upper  end  of  the 
tube  is  expanded  into  a  head,  which  rests  on  the  ventricular 
bands,  and  prevents  the  tube  slipping  down  into  the  trachea. 
The  anterior  parts  of  the  head  is  bevelled  off  so  as  not  to  press  on 


DIPHTHERIA. 


373 


the  base  of  the  epiglottis.  There  is  a  small  hole  near  the  anterior 
part  through  which  a  thread  can  be  passed.  In  the  middle  of  its 
length  is  a  fusiform  enlargement,  by  which  the  tube  is  retained  in 
the  larynx.  Each  tube  is  supplied  with  a  so-called  obturator, 
which  is  inserted  into  the  tube,  and  fits  the  openings  accurately  at 
sach  end.  In  the  upper  end  of  the  obturator  is  a  small  hole  by 
which  it  can  be  screwed  on  to  the  introducer  when  the  tube  is  about 
to  be  used.  At  the  distal  end  the  obturator  projects  slightly,  so 
as  to  form  a  probe-pointed  extremity,  which  diminishes  the  risk  of 
injuring  the  parts  during  introduction.  The  introducer  consists 
of  a  handle  and  a  shank,  bent  at  its  distal  end  at  a  right  angle. 
To  this  end  the  obturator  is  screwed  on,  and  by  pressing  a  button 
in  the  upper  surface  of  the  handle  two  claws  can  be  made  to  pro- 
ject downwards  on  the  head  of  the  tube,  so  as  to  push  it  clear  of 
the  obturator,  and  to  allow  the  introducer  with  the  attached  ob- 
turator to  be  withdrawn  when  the  tube  is  in  position.  The  ex- 
tractor is  a  curved  instrument,  at  the  distal  extremity  of  which 
two  small  blades  can  be  made  to  dilate  by  pressure  on  a  spring  in 
the  handle.  The  extremity  is  inserted  into  the  tube  with  the 
blades  closed,  when  pressure  on  the  spring  causes  the  blades  to 
open,  and  the  tube  to  be  firmly  held. 

In  performing  intubation  the  first  step  is  to  select  a  tube  suit- 
able to  the  age  of  the  child,  which  may  be  done  approximately  by 
reference  to  the  scale.  The  tube  is  threaded  with  a  piece  of 
braided  silk,  some  sixteen  inches  long,  the  ends  of  which  are  tied 
together.  The  obturator  is  then  screwed  on  to  the  introducer, 
and  the  tube  is  fitted  on  to  the  obturator.  The  nurse,  seated- 
upright  in  a  straight-backed  chair,  takes  the  child  in  her  lap,  with 
its  back  pressed  against  her  left  chest,  and  its  head  thrown 
slightly  backwards,  resting  against  her  left  shoulder.  She  passes 
her  arms  round  the  child,  and  crosses  its  forearms  in  front,  and 
holds  the  wrists  tightly,  and  if  necessar}^  she  secures  the  child's 
legs  between  her  knees.  The  gag  is  next  placed  well  back  at  the 
left  corner  of  the  mouth,  and  an  assistant,  standing  behind  the 
nurse's  shoulder,  holds  the  gag  and  steadies  the  head  between  his 
hands.  The  operator,  standing  or  sitting  in  front  of  the  child, 
lakes  the  introducer  in  his  right  hand  and  hooks  the  loop  of 
thread  round  the  httle  finger  of  the  left  hand.  He  then  rapidly 
passes  the  index-finger  of  the  left  hand  over  the  tongue,  and 
behind  the  epiglottis,  till  the  upper  orifice  of  the  larynx  is  felt. 
With  the  handle  of  the  introducer  held  close  to  the  patient's 
chest,  the  tube  is  introduced  into  the  mouth,  and  passed  back  over 
the  base  of  the  tongue,  suided  by  the  index  finger,  and  kept  as 


374 


DISEASES  OF  THE  THROAT  AND  NOSE. 


nearly  in  the  middle  line  as  possible.  When  the  point  of  the 
tube  reaches  the  epiglottis  an  abrupt  turn  is  given  to  its  course  by 
raising  the  handle  of  the  introducer,  and  thus  bringing  the  tube 
into  a  vertical  position.  The  tip  is  then  passed  down  into  the 
larynx  along  the  palmar  surface  of  the  guiding  finger.  As  soon 
as  the  tube  is  in  the  larynx  it  is  detached  from  the  introducer  by 
pressing  forwards  the  button  on  the  handle,  and  as  the  introducer 
with  the  attached  obturator  are  withdrawn,  the  tube  is  pressed 
down  with  the  tip  of  the  left  index  finger  until  the  head  is  felt  to 
rest  on  the  ventricular  bands,  when  the  finger  is  at  once  with- 
drawn. 

Fig.  CXXV.  b,  which  is  taken  from  ^"^Dr.  Waxham's  book, 
represents  the  curve  that  should  be  made  by  the  end  of  the  tube 
while  it  is  being  introduced,  the  dark  line  indicating  the  path  it 
should  follow.    If  the  point  of  the  tube  be  continued  in  the  curve, 


as  indicated  by  the  dotted  line,  it  will  invariably  enter  the  oeso- 
phagus. 

The  entry  of  the  tube  into  the  larynx  is  indicated  by  violent 
coughing,  quickly  followed  by  easy  breathing.  I  have  been 
astonished  by  the  rapidity  with  which  the  bases  of  the  lungs  are 
aerated,  and  if  there  is  any  doubi  as  to  the  position  of  the  tube, 
the  surgeon's  ear  applied  to  the  back  of  the  little  patient  will  often 
settle  it.  If  it  has  passed  into  the  oesophagus  there  is  no  violent 
coughing,  and  no  relief  is  given  to  the  breathing,  and  the  loop  of 
thread  will  be  found  gradually  shortening  as  the  tube  sinks  into 
the  oesophagus.  In  that  case  the  loop  should  he  pulled  upon  and 
the  tube  withdrawn.  When  quite  satisfied  that  the  tube  is  in  the 
larynx,  the  operator  removes  the  gag  and  waits  a  few  minutes  to 
allow  the  cough  to  remove  the  mucus  and  fragments  of  softened 
membrane.  It  is  recommended  that  the  gag  should  be  then  re- 
placed, and  the  loop  cut  close  to  the  mouth,  and  while  the  left 


c 


Fig.  CXXV.  d. 


DIPHTHERIA. 


575 


index-finger  is  passed  down  on  the  head  of  the  tube  to  steady  it, 
the  thread  should  be  drawn  out,  but  in  many  cases  it  is  better 
to  leave  the  thread  in  for  a  short  time,  fastening  it  to  one  or  other 
cheek  of  the  patient's  face  by  a  small  strip  of  plaster. 

When  the  tube  has  to  be  extracted,  the  patient  is  placed  in  the 
same  position  as  for  introduction.  The  gag  is  inserted,  and  the 
left  index-finger  is  passed  behind  the  epiglottis  till  it  feels  the 
opening  in  the  head  of  the  tube.  The  extractor,  in  the  right 
hand,  is  introduced,  and  its  point  guided  into  the  opening  by  the 
finger.  By  pressing  on  the  lever  in  the  handle,  the  blades  are 
dilated,  thus  holding  the  tube  firmly  while  it  is  withdrawn. 

Intubation  of  the  larynx  is  an  easy  and  safe  operation  in  the 
hands  of  an  operator  possessed  of  moderate  dexterity  and  a 
thoroughly  practical  acquaintance  with  the  parts  dealt  with,  but 
to  one  not  accustomed  to  put  his  finger  in  this  part  of  the  throat 
the  first  attempt  will  often  be  attended  with  difficulty  or  failure. 
As  I  have  remarked  in  the  paper  already  referred  to,  it  is  in  a 
sense  a  tribute  to  the  merit  of  intubation  that  the  most  successful 
results  have  hitherto  been  obtained  by  practitioners,  not  laryngeal 
specialists.  With  the  gag  in  the  mouth  it  is  perfectly  possible  to 
see  the  glottis  with  the  laryngoscope,  especially  with  the  aid  of  Dr. 
Bleyer's  traction  hook,  which  exposes  the  epiglottis  ;  and  it  is 
certainly  more  easy  and  rational  to  introduce  the  tube  by  means 
of  the  eye  than  by  the  sense  of  touch,  especially  as  by  the  intro- 
duction of  the  hand  there  is  great  risk  of  increased  suffocation, 
as  well  as  of  injury  to  the  soft  parts  in  a  condition  of  inflamma- 
tion or  ulceration.  Moreover,  to  learn  the  knack  of  introducing 
an  instrument  by  sight  requires  no  more  practice  than  the  guiding 
of  it  by  the  sole  aid  of  the  finger. 

After  the  tube  has  been  placed  in  the  larynx,  and  after  the  first 
effects  of  irritation  have  passed  off,  respiration  will  usually  be 
carried  on  easily.  It  has  occasionally  happened  that  during  the 
introduction  false  membranes  have  been  detached  and  pushed 
down  before  the  tube,  thus  causing  suffocation.  The  accident  is 
rare,  and  when  it  has  happened,  immediate  removal  of  the  tube 
has  almost  invariably  been  followed  by  coughing  up  of  the  mem- 
brane. Should  this  not  occur,  tracheotomy  should  be  done,  and 
it  is  therefore  well  to  have  tracheotomy  instruments  ready  at 
hand. 

During  the  course  of  the  treatment,  the  tube  is  cleared  of 
mucus  by  the  ordinary  efforts  of  respiration  and  cough.  If  it 
become  clogged,  it  is  usually  coughed  up.  There  is,  as  a  rule,  no 
danger  of  suffocation  in  such  cases  for  some  hours,  so  that  ample 


376  DISEASES  OF  THE  THROAT  AND  NOSE. 


time  is  usually  allowed  to  summon  the  physician  or  surgeon  in 
charge.  Sometimes  the  tube  is  coughed  up  independently  of 
getting  blocked.  When  the  tube  is  very  easily  coughed  up,  it  is 
an  indication  that  the  size  used  is  too  small.  It  is  usually  ejected 
from  the  mouth,  but  it  has  occasionally  been  swallowed,  and  in 
all  the  recorded  cases  where  this  has  happened  (with  one  excep- 
tion, when  it  was  found  post  mortem  no  further  down  than 
the  stomach),  it  has  been  passed  without  difficulty  per  rectum. 
The  tube  must  be  extracted  at  any  period  of  the  treatment 
if  there  are  symptoms  of  its  being  obstructed.  Otherwise 
most  operators  do  not  interfere  with  it.  In  the  course  of 
from  four  to  six  days  the  swelling  and  spasm  will  have  so  far 
diminished  that  the  tube  will  be  coughed  up,  and  it  will  then  pro- 
bably be  found  that  it  is  no  longer  required.  If,  about  the  sixth 
da}^  it  be  not  coughed  up,  it  should  be  removed  with  the  extractor, 
and  need  not  again  be  introduced  if  the  breathing  is  easy. 

Some  children,  after  intubation,  swallow  without  difficulty  both 
liquids  and  solids.  In  others,  each  attempt  to  swallow,  more 
especially  liquids,  excites  cough,  owing  to  the  entry  of  some 
portion  into  the  air-passages.  Semi-solid  food  is  therefore  pre- 
ferable. It  is,  however,  usually  possible  to  overcome  the  difficulty 
of  swallowing,  even  of  liquids,  by  placing  the  child  on  its  back  in 
a  horizontal  position  with  its  head  hanging  backwards,  as  de- 
scribed by  "^"^Casselbury.  In  this  position  the  child  may  suck  from 
a  bottle  or  be  fed  with  a  spoon.  In  some  cases  the  child  swallows 
as  well,  or  better,  lying  on  the  abdomen  with  the  head  hanging 
forwards — that  is,  in  the  same  position  as  that  found  to  be  con- 
venient in  cases  of  dysphagia,  due  to  tuberculous  ulceration  of 
the  epiglottis.  In  a  series  of  intubations  recently  performed  at 
the  Victoria  Hospital  for  Children  there  was  little  difficulty  of 
swallowing  noted.  I  have  had  two  cases,  however,  in  which  it 
was  a  source  of  some  trouble  at  first. 

In  young  children  intubation  has  given  better  results  than 
tracheotomy.  ^^Stern's  statistics  show  that  under  three  and  a 
half  years,  intubation  gives  a  decidedly  larger  number  of  recoveries. 
Being  a  bloodless  operation,  and  not  requiring  an  anaesthetic,  the 
consent  of  parents  is  more  easily  obtained,  and  thus  children  are 
saved  who  would  otherwise  die,  owing  to  inability  to  obtain  the 
parents'  consent  for  tracheotomy.  For  a  similar  reason,  the  opera- 
tion can  be  performed  earlier,  before  the  patient  is  moribund — as 
too  often  happens  with  tracheotomy.  Finally,  for  the  poor  in 
their  own  homes,  I  think  it  is  decidedly  superior  to  tracheotomy. 
The  tracheotomy  tube  requires  constant,  and  even  skilled  atten- 


DIPHTHERIA. 


377 


tion,  whereas  the  intubation  tube,  once  in  place,  as  a  rule  takes 
care  of  itself. 

5.  Hygienic  and  prophylactic  measures  to  be  observed  with 
regard  to  diphtheria  differ  in  no  respect  from  what  would  bo 
required  in  the  case  of  any  other  infectious  or  contagious  disease. 
They  consist  essentially  in  the  embracing  of  every  opportunity  of 
purifying  the  air  of  the  sick-room,  and  purging  it  of  exhaled  and 
volatile  toxic  ingredients  that  may  be  generated.  This  purpose 
is  best  effected  by  securing  to  the  patient  an  atmosphere  well 
charged  with  oxygen,  and  by  taking  every  other  precaution 
against  a  further  development  of  the  poison  as  conveyed  in  the 
defecations  and  eliminations  of  the  tainted  individual. 

The  patient  must  therefore  be  isolated  as  far  as  possible  from 
other  inmates  of  the  house,  and  be  placed  in  a  large  airy  room, 
the  temperature  of  which  should  be  regulated  according  to  the 
season  of  the  year  and  the  barometric  condition  of  the  atmosphere. 
If  the  case  occur  in  the  winter  months,  the  wind  being  in  the  north 
or  north-east,  the  air  of  the  room  is  not  only  to  be  well  warmed, 
but  also  softened  by  steam  ;  if  in  foggy  weather,  with  wind  in  the 
south-east,  a  drier  warmth  is  indicated.  If,  on  the  other  hand, 
the  case  occur  during  the  summer,  fresh  air,  with  precautions 
against  draught,  may  be  admitted  to  a  much  freer  extent,  and  steam 
may  be  almost  dispensed  with.  All  excretions  should  be  treated 
with  strong  liquid  disinfectants,  and  the  w.c.  employed  for  their 
bestowal  should  not  be  used  even  by  the  immediate  attendants. 

Since  disinfection  of  the  atmosphere  by  chlorine,  euchlorine, 
iodine,  bromine,  sulphurous  acid,  or  any  of  the  other  more  active, 
but  somewhat  suffocative  disinfectants  is  not  always  possible  in 
the  patient's  room  or  immediate  neighbourhood,  the  atmosphere 
passing  to  and  fro  the  doors  and  passages  of  the  sick-room  may 
be  asepticized  by  sheets  soaked  in  Burnett's  fluid,  Sanitas,  Euca- 
lyptus, and  similar  solutions.  A  '  Sanitas  '  kettle  may  be  con- 
veniently placed  outside  the  room,  so  that  when  the  door  is  opened, 
the  air  comes  in  not  only  warm  and  moist,  but  impregnated  with 
oxidizing  constituents.  Sprays  of  Condy,  Sanitas,  etc.,  by  means 
of  hand-ball  or  steam  atomizers,  may  also  be  employed. 

After  tracheotomy  loca  precautions  against  admitting  untem- 
pered  air  through  the  tracheal  tube  must  be  rigidly  pursued. 

In  view  of  the  possible  occurrence  of  syncope,  the  patient 
should  be  kept  perfectly  quiet  as  regards  bodily  movement,  and 
should  be  nourished  by  means  of  '  feeders,^  so  as  not  to  allow 
even  the  raising  of  the  head  from  the  pillow. 

I  have  for  many  years  insisted  that  all  persons  in  immediate 


378 


DISEASES  OF  THE  THROAT  AND  NOSE. 


attendance  on  diphtheritic  patients  should  gargle  freely  with  some 
antiseptic  or  detergent  solution  (Form.  8,  9,  10,  11)  after  each 
ministration  that  may  have  involved  standing  over  the  patient  in 
such  a  way  as  to  have  inhaled  the  breath.  I  would  also  suggest 
a  more  general  adoption  by  them  than  now  obtains  of  the  nasal 
.  douche,  containing  antiseptic  or  detergent  remedies  (Form.  72, 
73,  74,  76,  77,  or  78).  Lozenges  of  chlorate  of  potash,  carbolic 
acid,  etc.,  are  also  useful  for  this  purpose.  Lastly,  I  always 
personally  give  effect  to  a  hint  derived  from  a  sanitary  architect, 
who,  whenever  he  is  obliged  to  inhale  any  unpleasant  effluvium, 
blows  his  nose  freely,  gathers  his  saliva,  and  expectorates. 

Addendum. 

^•'Booker  has  recently  published  the  results  of  a  series  of  experiments  on  the  mem- 
branous exudations,  occurring  in  the  course  of  scarlet  fever,  and  the  exanthemata 
generally. 

The  conclusions  he  arrives  at  are  : — 

(1)  That  although  these  exudations  often  closely  resemble  those  of  diphtheria,  yet 
they  differ  in  their  nature  and  etiology. 

(2)  That  the  symptoms  in  diphtheria  depend,  not  upon  the  direct  action  of  the 
bacilli,  but  on  the  toxic  alkaloids,  etc.,  to  which  they  gjve  rise. 

(3)  That  measles  and  scarlet  fever  render  the  tissues  a  favourable  soil  for  the 
development  of  the  bacillus  of  diphtheria. 

These  conclusions  are  in  accord  with  the  published  opinions  of  Rualt,  Baginsky,  and 
others  ;  and  it  is  justifiable  for  the  author  of  this  book  to  note  that  they  confirm  the 
opinions  advanced  by  him  in  the  Second  Edition,  published  in  1887,  but  which  were  then 
strongly  contested  and  disputed  by  many  able  reviewers. 

They  also  support  the  author's  opinion  that  the  views  of  Gottstein  and  Morell-Mac- 
kenzie,  that  the  secondary  laryngeal  exudations  which  so  often  follow  on  the  exanthemata, 
are  of  the  nature  of  a  true  diphtheria,  are  incorrect,  in  the  light  of  the  most  recent 
researches  in  bacteriology. 

Finally,  they  justify  the  author's  insistence  on  the  important  part  played  by  the  toxic 
alkaloids  which  are  the  outcome  of  bacillary  action,  in  the  production  of  those  asthenic 
constitutional  manifestations  of  diphtheria,  which  are  represented  by  cardiac  failure, 
paralyses,  etc.  And  once  again,  these  latest  views  also  disprove  the  theory  that  originated 
from  the  report  of  the  Royal  Medico-Chirurgical  Society's  Committee,  quoted  in  the  text, 
that  all  membranous  exudations  in  the  throat  and  larynx  are  of  the  same  nature — a  theory 
ihat,  as  the  result  of  early  clinical  experience,  the  author  has,  almost  alone  among 
specialists,  persistently  and  consistently  opposed. 


REFERENCES  TO  AUTHORITIES. 

PAGE,    j  NO. 

NAME. 

TITLE  OF  WORK  REFERRED  TO. 

335 
335 
336 
336 

336 

336 
336 
337 

2 

3 

4 

5 

6 

7 
8 

\{  DiphtJieria,    its    Nature,    etc.,    p.  ii. 
j  t    London,  1879. 
-r,                                    i Memoirs.    Translated  by  Semple.  New 

BuETONNEAU.                     \      o    i     u        c     •  ^  rCi-^ 

1       Sydenham  Society,  1859. 
,^    ^_                             U  Quoted  by  Trouessart  in  J//r/'(?^^j",/vr///c';//'j-, 
|\    and  Moulds, ^^.220,22\.   London,  1 886 

fLOFFLEK,  CORXIL,  AND"\    j,  •  , 

I    Babes.               .  ^f'"^' 
Emmerich.                  {^'/s^^'  ^^'''^''"''^'''^'^ 
Wood  and  Formad.      Quoted  by  Trouessart.    Loc.  cit.,  p.  215. 
Roux  and  Yersin.       ^Ann.  Inst.  Pasteur,  1888. 
Sidney  Mak.tin.          \Brit.  Med.  Journal,  vol.  1.,  p.  700.  1892. 

DIPHTHERIA. 
REFERENCES  TO  AUTHORITIES— (Ct;;//^^^?^/). 


379 


TLE  OF  WORK  REFERRED  TO. 


33S 

9 

Trousseau. 

10 

Ren  SHAW. 

339 

1 1 

HUEBxXER. 

339 

12 

Oertel- 

339 

13 

S  CHECH. 

340 

H 

ThURSI'IKLD. 

341 

15 

i^LSLIh  JrHILiLlrb. 

343 

HILL. 

344 

17 

liUHL. 

345 

18 

Virchow. 

345 

19 

Niemeyer. 

345 

Virchow. 

351 

21 

Wagner. 

351 

22 

Jenner. 

('Scientific  Commit- 

23 

\    tee  of  Roy.  Med. - 

\    Chirurg.  Society. 

354 

'7/1 

R  A  P  T  M    T»'  V 

354 

25 

"n?  r  T  A  T  T  T  '  P 
1\.UAUL1. 

26 

Jacobi. 

358 

27 

Fagge. 

350 

l^ER  1  EL. 

359 

29 

Trideau. 

359 

30 

JjJl,V  l!,Kl^ll,V    ixL/iJ  1  IN  bU  IN  . 

359 

31 

Sansom. 

359 

32 

r  ONTAINE. 

359 

33 

Stepf. 

359 

34 

Rose -Cor  MACK. 

362 

35 

TOBOLD. 

362 

36 

SoLis  Cohen. 

36^ 

37 

Oertel. 

363 

Bloebaum. 

364 

39 

"\Ttv 
IN  IX. 

365 

40 

Watson  Cheyne. 

365 

41 

May. 

365 

42 

MoRELL-  Mackenzie. 

369 

43 

Lennox  Browne. 

369 

44 

G.  M.  Lefferts. 

371 

45 

Lennox  Browne. 

374 

40 

Waxham. 

376 

47 

Casselbury. 

376 

48 

Stern. 

378 

49 

Booker. 

Alefiioirs.    Translated  by  Semple,  1859. 
Bn't.  Med.  Journ.,  vol.  li.,  p.  837,  1885. 
\  Die    experijuentelle  Diphtlieria.  Prize 

Essay.    Leipzig,  1883. 
Archives  0/  Larynigology,  p.  37.  New 

York,  1881.    See  also  Ziemssen^s  Cyc. 

of  Med.,\o\.  iv.,  English  edition;  and 

Respiratory  7 herapeiilics,  translated  by 

Yeo,  vol.  i.    London,  1885. 
Op.  cit.,  p.  144. 
La)icct,  vol.  ii.,  1878. 

B7'it.  I\Ied.  Journal,  1886,  vol.  i.,  p.  1 061. 
Lancet^  March  9,  1889. 

Zeitschrift  fiir  Biologic^  Band  iii.,  S.  367, 
1867. 

Archiv,  p.  253.  1847, 
Op.  cit. 

\  Haudbitch  der  Spec.  Path,  iind  Therapie, 
\     vol.  i.,  p.  292.  1854. 
\  Zieinsseii^s  Cyc.  of  Med.^  vol.  vi.,  English 
\     edition,  1876-7. 
Diphtheria,  its  Nature  and  Treatment, 
London,  1861. 

r  Report  of  the  Committee,  p.  32.  London, 
I  1879. 

Deutsche  Med.  Wochenschr.,  1885. 

Article  in  Maladies  de  la  Bouche  et  du 
Pharynx.  Traite  de  Medecine.  Pans, 
1892. 

Brit.  Med.  Journ.,  vol.  ii.,  18S8.  p.  651. 
Op.  cit. 

Op.  cit.,  p.  43. 

Gaz.  Hebdom.,  March  28,  1887. 
Amer.  Journ.  Med.  Sciences,  p.  30,  1876. 
The  Antiseptic  System,  p.  332.  London, 
undated. 

Quoted  by  Trouessart.    Loc.  cit.,  p.  219. 
\  Brit.  Med.  Journal,  March  5,  18S7,  from 
\     Deutsche  Med.  IVochenschrift. 
Quain's  Dictionary  of  Medicine,  p.  380. 

London,  1883. 
Trans,  of  Internal.  Med.  Con^^rcss,  p,  203, 
1881." 
Op.  cit.,  p.  174- 
Loc.  cit.,  p.  38. 

Lancet,  1^.  (fi^.    November  20,  18S6. 
Ibid. 

Brit.  Med.  Jouriial,  March  5,  1SS7. 
Lancet,  September,  21,  1889. 
Op.  cit.,  p.  166. 

Trans.  Med.  Soc.  Loud.,  p.  200.  1S79. 
{ Archiv.  of  LaryngoL,  vol.  ii.,  p.  82.  New 
\    York,  1882. 

Brit.  Med.  Journ.,  March  9,  1S89. 
Intubatio7i  of  the  Lajyny.,  Chicago,  1S88. 
A  new  method  of  feeding  in  cases  of 
Intubation,  Chicago  Medical  Journal 
and  Examiner,  October,  1888. 
Transactions  of  the  International  Aledical 
Congress,  1 887. 
(Bulletin  of  the  Johns  Hopkins  Hospital, 
\    vol.  iii.,  26,  p.  109. 


CHAPTER  XVIII. 


SYPHILITIC  LARYNGITIS. 

(Figs.  56  to  67,  Plate  VII.) 

The  mucous  membrane  of  the  larynx  may  exhibit  the  specific 
manifestations  of  this  disease  in  either  the  secondary  or  tertiary 
stages.  The  great  frequency  of  syphihtic  laryngitis  is  described 
by^Gerhardt  as  largely  influenced  by  fortuitous  catarrhal  inflamma- 
tion, and  the  experience  of  all  laryngoscopists  in  hospital  practice 
will  confirm  this  view.  Another  predisposing  cause  to  the  greater 
amount  of  advanced  syphilitic  disease  of  the  larynx  in  the  poor, 
doubtless  exists  in  the  apathy  and  neglect  with  which,  after  long 
existence,  such  affections  are  treated,  and  also  often  to  a  badly 
nourished  state  of  the  body. 

SECONDARY  SYPHILIS  (Figs.  56  and  57,  Pl\te  VII.).- 

The  larynx  is  affected  at  this  period  of  the  disease  at  any  time 
from  six  months  to  two  years  after  exposure  to  the  primary 
infection.  Syphilitic  laryngitis  is  present  only  in  a  comparatively 
small  proportion  of  cases  of  all  varieties  of  throat  disease,  but 
syphilographers  differ  so  widely  as  to  the  ratio  in  which  the 
larynx  is  implicated,  that  no  useful  conclusions  can  be  drawn  from 
their  statistics.  According  to  ^Lewin,  the  larynx  is  affected  in 
4*8  per  cent,  of  all  cases  observed,  whilst  ^Willigk  gives  15*1, 
*Roth  32,  and  ^Sommerbrodt  34  per  cent,  as  the  proportion. 
All  agree  that  it  may  occur  either  as  an  extension  from  the 
pharynx,  or,  as  is  more  commonly  the  case,  at  a  somewhat 
later  period,  and  independently  of  the  pharyngeal  manifesta- 
tion. The  truth  of  this  last  suggestion  is  evidenced  by  the  fact 
that  the  larynx  is  often  first  affected  after  the  disease  in  the 
pharynx  has  been  cured,  or  without  the  latter  ever  having  suffered 
to  such  an  extent  as  to  call  for  medical  aid ;  the  characteristics 
also  of  secondary  inflammation  in  the  larynx  are  by  no  means  so 
differentially  distinctive  as  are  those  in  the  fauces.    It  may  be 


SYPHILITIC  LARYNGITIS, 


38i 


broadly  stated  that  the  probabihty  of  the  larynx  becoming  impli- 
cated stands  in  direct  ratio  to  the  duration  and  virulence  of  the 
infection,  and  in  a  large  degree  to  prompt  and  persistent  adoption 
of  appropriate  therapeutic  measures  from  its  first  manifesta- 
tion. 

Secondary  syphilis  in  the  pharynx  is  almost  invariably  accom- 
panied by  cutaneous  manifestations,  whereas  if  the  latter  have 
ever  been  noticed,  they  will  often  have  disappeared  months 
before  the  larynx  is  affected. 

Mucous  deposit  also  is  rare,  and  by  no  means  a  constant  product 
of  syphilitic  inflammation  occurring  in  the  larynx  ;  nor  is  such 
inflammation  or  such  deposit  invariably,  or  indeed  usually, 
symmetrical.  Loss  of  tissue  is  infrequent,  and  ulceration,  which 
seldom  extends  beyond  erosion  of  the  epithehal  layers,  occurs  at 
points  likely  to  be  subjected  to  irritation  from  the  passage  of  food 
or  from  mutual  contact  in  vocal  exercise. 

Condylomata  not  infrequently  occur  in  various  situations  in 
the  larynx — notably  in  the  epiglottis.  Their  presence  is  denied 
by  some  observers,  while  others  estimate  their  manifestation  in 
proportions  varying  from  i  to  36  per  cent. ;  Morell-Mackenzie 
in  ^i8y6  reported  that  he  had  found  them  only  twice  in  fifty-six 
cases,  but  in  ''1880  had  '  met  with  forty-four  cases  of  condyloma 
among  118  patients  suffering  from  the  early  symptoms  of  lar3mgea] 
syphilis.'  These  two  statements  constitute  a  great  discrepancy — 
the  first  represents  a  proportion  of  about  4  per  cent.,  while  the 
second  of  38  per  cent,  agrees  closely  with  that  of  Gerhardt  and 
Roth  who,  as  previously  stated,  found  condylomata  in  32  per 
cent. — that  is,  in  eighteen  instances  out  of  fifty-six  patients  suffer- 
ing from  constitutional  syphilis — to  which  statement  Mackenzie 
had  pointedly  objected  in  his  earlier  views.  These  differences 
depend  partly,  as  the  last  author  has  said,  on  the  time  of  year 
that  examinations  are  made,  and  partly,  it  may  be  added,  to  the 
limit  ascribed  to  the  secondary  stage. 

Contrary  also  to  the  experience  of  Mackenzie,  I  have  seen  not 
a  few  cases  in  which  condylomata  have  developed  into  formations 
which  were,  to  all  intents  and  purposes,  warty  growths;  nor  can  I 
agree  that  such  formations  have  in  the  larynx,  any  more  than  on  the 
skin,  at  points  where  irritation  is  constant,  a  tendency  to  spontaneous 
subsidence.  All  secondary  syphilitic  aftections  of  the  larynx  are 
characterized,  as  are  those  associated  with  the  same  dyscrasia  in 
other  organs,  by  rapid  amelioration  under  appropriate  treatment, 
but  by  an  equally  strong  tendency  to  relapse.  This  fact  is  often 
of  great  diagnostic  value  in  doubtful  cases  of  chronic  laryngitis. 


382 


DISEASES  OF  THE  THROAT  AND  NOSE. 


With  regard  to  this  disposition  to  relapse  ^Whistler  has  called 
deserved  attention  to  the  '  relapsing  ulcerative  laryngitis '  which 
marks  what  he  has  called  the  intermediary  stage  of  syphilis.  In 
this  condition  the  ulcerations,  though  more  superficial  than  in  the 
true  tertiary  stage,  imply  a  deeper  loss  of  tissue  than  in  the  more 
commonly  seen  erosions  of  the  true  secondary.  They  probably 
indicate  not  only  a  more  pronounced  specific  taint,  but  are  also 
caused  by  a  greater  degree  of  adventitious  inflammation  of  the 
larynx  in  the  first  instance. 

Symptoms  :  A.  Functional. — Under  the  influence  of  severe 
atmospheric  or  other  exciting  cause  of  laryngitis  the  voice  of  a 
syphilitic  person  is  much  more  liable  to  be  completely  lost,  and  is 
restored  less  quickly  and  completely  than  in  a  non-specific  case. 
It  may  be  stated  generally  that  alteration  of  this  function  is 
characterized  by  early  and  very  persistent  husky  hoarseness. 
When  once  appreciated,  the  raucous  syphilitic  voice  is  so  dis- 
tinctive that  the  practised  ear  will  recognise  the  disease  as  soon 
as  the  patient  speaks. 

Vocal  exertion  always  increases  the  dysphonia,  and  the  singing 
voice  is  entirely  destroyed  for  the  time  :  it  is,  indeed,  doubtful 
whether  a  vocalist  who  has  once  suffered  from  syphilitic  congestion 
of  the  vocal  cords  ever  regains  complete  purity  of  tone,  submucous 
changes,  slight  though  they  may  be,  preventing  perfect  co-aptation 
and  co-ordination  of  those  structures. 

Respiration  is  but  seldom  embarrassed,  but  the  breathing  is 
frequently  described  by  the  patient  as  wheezy.  Extension  of  the 
inflammation  into  the  trachea  and  larger  bronchi  is  common,  and 
on  auscultation  rales  may  be  often  heard. 

Cough  is  only  occasioned  by  the  desire  to  clear  away  expectora- 
tion, or  after  the  irritation  caused  by  talking  or  eating. 

Pain,  except  a  sense  of  effort  in  the  use  of  the  voice,  is  rarely 
experienced  in  the  earlier  forms  of  laryngeal  syphilis. 

B.  Physical. — Colour. — On  looking  into  the  larynx  of  a 
patient  suffering  from  secondary  syphilis,  one  is  struck  first 
by  the  somewhat — not  always,  however,  well-defined — mottled 
discoloration,  and  secondly  by  the  fact  that  the  hypersemia  does 
not  appear  to  be  so  superficial,  nor  so  vivid  in  colour,  as  in 
simple  chronic  inflammation.  This  distinctive  appearance  is 
more  particularly  seen  on  the  vocal  cords,  which  are  observed  to 
be  more  or  less  congested,  in  patches  of  varying  intensity,  the 
non-hyperasmic  portions  being  of  a  greyish  tone.  Mucous  deposits 
when  present  are  visible  most  frequently  on  one  or  other  ven- 
tricular bands,  on  the  free  edge  of  the  epiglottis,  the  arj^tenoid 


SYPHILITIC  LARYNGITIS. 


383 


cartilages,  and  at  the  posterior  commissure.  Gotistein  well 
describes  the  appearance  of  mucous  patches  as  that  of  '  round  or 
elongated  greyish-white  spots  of  thickened  epithelium  slightly 
raised  above  the  congested  tissue  which  surrounds  them,  and  are 
either  sharply  circumscribed  or  shade  gradually  off  into  it.' 

Form  and  Texture. — Beyond  occasional  slight  want  of  equality 
in  muscular  action,  there  is  seldom  alteration  of  form.  Condylo- 
mata are  occasionally  seen  on  the  inter-arytenoid  fold,  and 
on  the  free  edge  or  lingual  surface  of  the  epiglottis.  In  long- 
standing cases,  and  when  the  voice  is  unduly  exercised,  there 
may  be  loss  of  surface-tissue  on  the  arytenoid  cartilages  and  on 
the  vocal  processes.  It  is  comparatively  rare  to  find  erosion  of 
any  other  portion  of  the  vocal  cords. 

Secretion,  in  secondary  syphihs,  is  scanty  and  viscid,  the  patient 
frequently  making  a  point  of  complaint  that  the  cough  is  very  dry. 

C.  Miscellaneous. — External  signs  of  syphilis  on  the  skin 
are  often  wanting,  for  the  reasons  already  given,  and,  when  the 
pharynx  has  not  been  attacked,  they  may  have  been  so  slight  as 
to  have  entirely  escaped  the  notice  of  the  patient.  The  most 
uniform  corroborative  symptom  is  that  of  post-cervical  glandular 
enlargement,  but  that  cannot  be  said  to  be  by  any  means 
universal.  In  fact,  the  surgeon  will  often  be  at  a  loss  to  arrive  at 
a  distinct  conclusion  as  to  the  nature  of  the  disease  from  the 
usual  commemorative  signs,  especially  in  the  case  of  those 
patients  (married  women,  for  example)  of  whom  it  is  unadvisable, 
for  ethical  and  family  reasons,  to  ask  questions.  In  such  cases, 
reliance  must  be  mainly  placed  on  the  results  of  physical  investi- 
gation of  the  larynx  itself. 

The  general  health  is  of  course  tainted  by  the  specific  poison, 
but  it  does  not  suffer  to  the  same  extent  as  in  the  earlier  or  in 
the  much  later  epochs  of  the  disease.  Thus  there  is  seldom 
much  variation  in  temperature,  though  there  may  be  slight  fever 
at  night ;  the  surface  temperature  may  be  ordinarily  rather 
increased,  and  the  perspiration  somewhat  scanty.  All  the 
symptoms  suffer  some  nocturnal  exacerbation. 

Prognosis. — The  course  of  the  disease  under  treatment  is 
favourable,  though,  as  intimated  above,  the  chances  of  a  per- 
manent loss  of  singing  voice  or  of  a  chronic  hoarseness  are  not  to 
be  overlooked,  nor  the  possibility  of  the  development  of  quasi- 
new  formations. 

There  is  a  strong  disposition  to  relapse  on  the  slightest  catarrhal 
provocation,  and  this  tendency  is  naturally  somewhat  increased 
during  the  time  the  patient  is  under  active  treatment. 


3«4 


DISEASES  OF  THE  THROAT  AND  NOSE, 


Treatment  :  General. — A  mild  mercurial  course  is  naturally 
indicated,  and  is  most  serviceable.  The  Turkish  bath,  followed 
by  the  calomel  vapour-bath  or  by  moderate  mercurial  inunction, 
is  of  great  value,  both  for  its  general  and  local  effects. 

Whenever  condylomata  appear,  or  when  there  is  any  symptom 
of  ulceration,  iodide  of  potassium  or  sodium,  with  or  without 
mercury,  is  indicated. 

Local. — Stimulating  inhalations,  of  precisely  the  same  character 
as  were  recommended  in  simple  chronic  laryngitis,  are  of  the  first 
importance.  External  applications  of  tincture  of  iodine,  or  mer- 
curial ointment  with  iodine  and  belladonna,  have  a  decidedly 
beneficial  effect. 

Topical  applications  to  the  larynx  are  of  far  greater  value 
than  in  simple  chronic  congestion,  and  must  be  pursued  with 
proportionately  greater  regularity  and  perseverance,  even  after 
the  inflammation  has  disappeared  from  the  vocal  cords.  Allusion 
has  already  been  made  to  the  absence  of  warrant  for  the  traditional 
preference  of  the  profession  for  nitrate  of  silver  in  laryngeal  disease. 
This  remedy  should  only  be  applied  when  there  is  actual  ulcera- 
tion. Solutions  of  chloride  of  zinc  and  of  sulphate  of  copper  are 
found  by  us  the  most  useful  as  local  applications  in  secondary 
inflammations ;  alternation  of  the  solutions  frequently  having  a 
great  eftect  in  promoting  the  cure.  In  very  obstinate  cases,  spa 
treatment  at  Aix-la-Chapelle  or  Bagneres  de  Luchon  may  with 
advantage  be  prescribed. 

Hygienic  and  Dietetic. — The  indications  are  to  give  rest  to 
the  voice,  and  to  avoid  exposure  to  all  catarrhal  or  irritative 
influences  of  atmosphere  and  nourishment. 

TERTIARY  SYPHILIS  (Figs.  58  to  67,  Plate  VII.).  , 

This  form  of  syphilis  is  characterized  by  ulceration  of  the  most 
destructive  character,  causing  permanent  loss  of  tissue,  foflowed 
by  resulting  cicatrices,  which  may  either  produce  great  narrowing 
of  the  larynx,  or  may  be  accompanied  by  new  deposit  having  the 
same  effect. 

It  occurs  in  the  throat  as  one  of  the  latest  manifestations  of 
the  disease,  and  is  often  seen  twenty  or  thirty  years,  or  even  at  a 
still  later  period,  after  the  primary  infection.  It  may  commence 
as  an  extension  of  the  disease  from  the  fauces,  in  which  case  it 
very  seldom  advances  beyond  the  epiglottis,  and  under  these 
circumstances  there  is  neither  much  thickening  nor  displace- 
ment, nor  any  great  amount  of  trouble  in  the  performance  of 
function. 


SYPHILITIC  LARYNGITIS. 


3«5 


From  the  velum,  or  posterior  wall  of  the  pharynx,  the  disease 
very  seldom  descends  into  the  larynx,  and  cases  may  frequently 
be  seen  in  which  the  whole  posterior  wall  of  the  pharynx  is  the 
seat  of  deep  ulceration,  extending  upwards  into  the  naso-pharynx ; 
but  in  which  the  larynx  is  absolutely  free  from  any  sign  of  ulcera- 
tion, and  in  which,  although  articulation  is  affected,  the  phonetic 
quality  of  the  voice  is  unaltered.  Such  was  the  condition  in  the 
case,  the  naso-pharyngeal  appearance  of  which  is  depicted  in 
Fig.  39,  Plate  V. 

These  remarks  hold  good  also  with  respect  to  congenital 
syphilis  in  the  larynx,  which  will  be  presently  considered. 

I,  however,  remember  a  case,  seen  some  fifteen  years  ago,  in  which  it  appeared  possible 
to  believe  that  the  patient,  a  young  man  of  22  or  23,  was  the  subject  both  of  hereditary 
syphilis  and  of  the  same  disease  in  the  acquired  form.  His  father  was  under  treatment 
for  tertiary  laryngeal  manifestations,  while  the  younger  man,  having  characteristic  teeth 
and  physiognomy,  and  with  cloudy  cornese,  had  been  under  medical  care  for  palatal 
ulceration,  acknowledged  to  the  primary  infection,  had  the  scar  of  a  chancre,  and  some 
years  after  his  first  appearance  as  a  patient  suffered  from  syphilitic  invasion  of  the  larynx. 

It  is  not  easy  to  affirm  that  the  ulcerative  process  is  always  the 
result  of  degeneration  of  gummatous  deposit,  since  the  patient 
frequently  does  not  come  under  observation  until  loss  of  tissue 
has  already  taken  place ;  but  from  the  appearance  of  those  ulcers 
which  are  the  undoubted  sequel  of  gummata,  it  seems  probable 
that  such  is  the  usual  origin  of  laryngeal  tertiary  ulceration. 

The  epiglottis,  subjected  as  it  is  to  greater  irritation  than  any 
other  part  of  the  larynx,  is  the  portion  most  frequently  attacked ; 
but  it  cannot  be  said  that  any  one  other  part  is  more  prone  than 
the  rest  to  the  destructive  process.  Gottstein,  however,  places 
the  vocal  cords  as  the  tissues  first  attacked,  then  the  epiglottis, 
and  lastly  the  posterior  commissure. 

Symptoms  :  A.  Functional. — Voice. — This  is  frequently  not 
at  all,  or  but  very  slightly,  affected  when  the  epiglottis  only  is 
attacked;  and  is  quite  restored  when  the  disease,  limited  to  that 
valve,  is  healed. 

Usually,  however,  permanent  hoarseness,  and  even  aphonia,  is 
a  prominent  symptom. 

Respiration  may  not  be  affected  even  when  there  is  con- 
siderable active  ulceration ;  but  on  cicatrization  embarrassment 
of  respiration  is  a  most  frequent  as  it  is  a  most  alarming 
symptom. 

Difficulty  of  breathing  may  also  be  due  to  actual  narrowing  of 
the  glottic  space  by  oedema  of  a  slowly  subsiding  and  readily 
relapsing  character,  and  also  by  the  formation  of  cicatricial 
adhesions  and  new  growths ;  it  may  further  depend  upon  infra- . 

25 


DISEASES   OF  THE  THROAT  AND  NOSE, 


glottic  stenosis  of  the  same  character,  or  upon  constriction  of  the 
trachea  just  above  the  bifurcation,  that  being  the  most  common 
seat  of  tracheal  stricture. 

Another  cause  of  dyspnoea  is  a  mechanical  one,  and  arises  from 
fixation  of  one  or  other  arytenoid  cartilage,  due  to  fibrous  deposit 
around  the  articulation.  Several  instances  of  this  kind  have 
come  under  my  observation.  In  such  a  case  the  vocal  cord  of 
the  affected  side  will  be  seen  to  be  paralyzed,  as  if  from  pressure 
on  the  recurrent  nerve ;  the  respiration,  however,  will  be  less 
impeded,  and  there  will  not  be  the  paroxysmal  exacerbations  so 
characteristic  of  nerve-pressure. 

Attacks  of  dyspnoea  will,  of  course,  vary  in  character  according 
to  their  cause.  When  due  to  stenosis,  there  will  be  stridor  on 
exertion,  and  on  the  occurrence  of  quite  slight  catarrh,  alarming 
attacks,  which  partake  of  all  the  characteristics  of  an  asthma. 
The  patient  may  recover  from  one  of  these  attacks,  and  enjoy 
comparative  immunity  from  recurrence ;  but  the  intervals  of 
remission  become  gradually  shorter,  until  at  length  they  become 
so  frequent  and  persistent,  that  hfe  is  threatened  by  exhaustion, 
by  laryngeal  or  tracheal  spasm,  or  by  asphyxia. 

Syphihtic  laryngeal  oedema  has  been  already  considered  in  the 
chapters  on  submucous  inflammations,  and  on  perichondrial 
changes.  As  pointed  out  in  the  latter  section,  extrusion  of  a 
cartilage  by  no  means  necessarily  follows  on  inflammation  or 
degeneration ;  for  it  not  infrequently  becomes  imbedded  in  con- 
nective or  fibrous  tissue. 

Cough. — In  the  ordinary  course  of  active  tertiary  inflammation 
there  is  nothing  to  call  for  special  remark  in  this  symptom, 
except  that  the  expectoration  is  of  a  distinctly  muco-purulent 
character,  and  often  contains  portions  of  disorganized  tissue ;  in 
which  case  there  may  be  more  or  less  haemorrhage.  Portions  of 
the  tracheal  rings,  or  of  the  laryngeal  cartilages,  or  even  a  whole 
arytenoid  cartilage,  may  be  expectorated. 

When  the  air-passages  are  narrowed,  the  cough  partakes  of  the 
characteristics  of  the  advanced  stage  of  oedematous  laryngitis 
with  stridulous  inspiration,  intense  spasm,  and  a  varying  degree 
of  aphonia.  When  there  is  constriction  of  the  trachea,  the  sound 
of  the  cough  cannot  be  mistaken  ;  it  resembles  more  than  any- 
thing that  of  laryngismus  stridulus,  or  of  whooping-cough  ;  but 
the  high  note  caused  by  obstruction  to  the  ex-spired  air  is  changed 
by  proceeding  from  lower  down  in  the  windpipe. 

The  expectoration  in  these  cases  is  of  the  scanty,  glairy 
-character  seen  in  asthma,  and,  as  in  that  disease,  relief  is  not 


SYPHILITIC  LARYNGITIS. 


3«7 


experienced  until  the  secretion  imprisoned  at  the  constricted  spot 
is  liberated. 

Deglutition. — This  is  naturally  impeded  when  the  epiglottis  is 
attacked,  though  it  is  surprising  how  much  of  that  valve  may  be 
lost  without  interfering  with  the  act  of  swallowing,  provided  the 
pharynx  be  not  also  involved.  Dysphagia  is  much  more  frequently 
experienced  when  the  pharyngeal  border  of  the  posterior  wall  of 
the  larynx  is  actually  diseased.  After-thickening  of  the  epiglottis, 
provided  its  hinge-movement  is  free,  does  not  appear  to  affect 
deglutition,  and  almost  the  whole  of  this  valve  may  be  destroyed 
without  any  impairment  in  the  function  of  swallowing.  Odyn- 
phagia is  rare,  and  the  same  may  be  said  with  regard  to  pain 
generally,  unless  there  be  perichondrial  inflammation;  and, 
indeed,  this  absence  of  pain  has  come  to  be  regarded  as  a 
differential  symptom  of  importance. 

B.  Physical. — Colour. — The  natural  colour  of  the  general 
surface  of  the  larynx  is  markedly  increased  in  intensity.  After 
the  ulceration  has  healed,  the  laryngeal  mucous  membrane  loses 
its  original  dehcate  semi-transparent  hue,  and  is  seen  to  be  of  an 
opaque  dullish  red.  Sometimes  this  redness  is  modified  by  a 
blue-greyness  of  tone.  It  will  be  noticed,  for  example,  that  the 
normal  warm  buff-colour  of  the  epiglottis  is  lost,  and  that  this 
part  will  look  as  if  of  exactly  the  same  structure  as  the  arytenoid 
cartilage.  The  ary-epiglottic  folds  will  appear  as  solid  as  the 
ventricular  bands,  and  the  vocal  cords  will  be  so  changed  in 
appearance  as  to  have  lost  all  their  pearly  lustre.  Sometimes  in 
the  stage  of  acute  inflammation  they  will  appear  to  have  quite 
degenerated  from  their  fibrous  firmness,  and  to  have  the  con- 
sistence and  colour  of  an  active  granulation.  When  the  disease 
has  become  very  chronic — that  is  to  say,  where  a  long  interval  has 
elapsed  since  the  last  inflammatory  attack — the  whole  surface  of 
the  larynx  often  acquires  a  greyish  or  yellowish  appearance  from 
submucous  changes. 

Gummata  in  the  larynx  have  been  described  by  ^Mandl  as 
having  a  greyish-yellow  tint,  but  by  ^^Tiirck  and  others  as  being 
of  the  same  colour  as  the  normal  mucous  membrane. 

As  seen  by  myself,  they  have  generally  exhibited  decidedly  in- 
creased vascularity  when  occurring  on  the  ventricular  bands, 
inter-arytenoid  fold,  and  arytenoid  cartilages ;  when  on  the 
epiglottis,  they  appear  as  nodes  of  a  somewhat  paler  colour  than 
the  congested  surface  from  which  they  spring-  Prior  to  breaking 
down,  gummatous  swellings  generally  assume  a  yellowish  hue  at 
the  central  and  most  superficial  point. 


3^8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Form  and  Texture. — The  order  of  appearances  under  this 
head  will  be  thus : — Loss  of  tissue,  thickening,  cicatricial 
narrowing. 

When  there  is  loss  of  tissue,  the  characteristic  of  the  tertiary 
syphilitic  ulcer  in  the  larynx  is  nothing  less  than  typical,  and 
cannot  be  better  described  than  in  the  words  of  Tiirck,  as  having 
*  a  more  or  less  circular  form,  a  deep  floor,  covered  with  a 
whitish  -  yellow  coating,  sharp,  sometimes  strongly  elevated 
margins,  surrounded  by  an  inflammatory  areola.'  It  need  only 
be  added  that  the  margin  is  hardly  circular,  but  appears  of  a 
multiple  crescentic  form ;  in  this  respect  somewhat  resembling 
the  manner  in  which  the  mucous  patches  appear  on  the  pharynx 
in  the  secondary  stage.  A  comparison  of  the  Plates  III.  and 
VII.  will  at  once  illustrate  and  elucidate  this  point. 

When  the  edge  of  the  epiglottis  is  ulcerated,  it  is  eaten  out  in 
distinct  notches  with  clean  edges ;  and  the  disease  will  proceed, 
by  the  way  of  the  ary-epiglottic  folds,  to  extend  to  the  rest  of 
the  larynx. 

The  secretion  of  the  ulcers  is  not  at  first  very  profuse,  and  is 
then  pale  in  colour  and  of  creamy  consistence  ;  but  when  the 
cartilages  become  attacked,  there  is  free  purulent  discharge, 
having  the  characteristic  odour  indicative  of  caries. 

The  thickening  of  tertiary  syphilis  on  healing  is  as  distinctive 
as  the  ulceration  which  precedes  it ;  occurring,  as  it  does,  as  a 
sequel  of  ulceration  instead  of  being  a  forerunner  of  that  process, 
as  in  phthisis,  and  being  of  the  nature  of  excessive  activity  of 
growth  at  the  periphery  of  the  ulcer,  with  marked  lack  of  pro- 
ductiveness at  the  centre.  We  have,  as  a  result,  contracting 
cicatrizations  of  dense  fibrous  unyielding  character,  very  difficult 
to  reduce,  and  very  apt  to  re-develop  on  division  and  dilatation. 
(See  Figs.  65  and  66,  Plate  VII.) 

Cicatricial  narrowing  of  the  larynx  is  attended,  as  we  have  seen 
to  be  the  case  in  oedematous  swelling  of  the  same  region,  with 
the  greatest  danger  to  life,  and  for  somewhat  similar  reasons— 
viz.,  not  only  because  there  is  narrowing  of  the  air-passages,  but 
also  because  there  is  very  frequently  a  superadded  impediment  to 
the  free  action  of  the  vocal  cords. 

A  case  is  delineated  as  Fig.  67  in  Plate  VIL,  in  which  the  left  arytenoid  cartilage 
having  been  expelled  as  a  result  of  ulceration  and  caries,  the  corresponding  vocal  cord 
became  paralyzed  and  then  atrophied. 

Position,  or  the  relative  situation  of  the  various  parts  of  the 
larynx,  may  be  greatly  altered  by  cicatricial  deformities.  Out- 


SYPHILITIC  LARYNGITIS. 


growths  from  the  pharyngeal  wall  are  often  observed.  They  are 
occasionalty  of  very  eccentric  shape,  and  not  uncommonly 
advance  across  the  laryngeal  opening,  but  they  seldom  exercise 
compression.  In  this  respect  they  differ  greatly  from  a  malignant 
encroachment  of  the  pharynx  on  the  larynx. 

C.  Miscellaneous. — There  is  seldom  any  external  local 
swelling  of  the  larynx,  except  in  occasional  cases  of  perichondritis 
of  a  specific  character.  The  constitutional  symptoms  need  not 
be  dwelt  upon,  except  to  say  that  the  absence  of  cachexia,  so 
frequently  to  be  noted,  is  of  marked  diagnostic  value  in  dif- 
ferentiating this  affection  from  phthisis  and  cancer. 

Prognosis. — This  must  always  be  guarded  in  a  case  of  tertiary 
disease  of  the  larynx,  if  there  is  the  least  evidence  either  of  peri- 
chondritis or  of  stenosis,  and  especially  if,  in  the  former  case,  the 
cricoid  cartilage  is  attacked.  Death  may  result  from  acute 
oedema  of  the  larynx,  occurring  suddenly  during  the  active 
ulcerative  process.  Another  possibility  of  fatal  termination, 
fortunately  not  a  common  one,  is  that  of  haemorrhage. 

If,  however,  the  disease  come  sufficiently  early  under  the 
notice  of  the  surgeon,  a  very  favourable  opinion  may  be  given, 
both  with  reference  to  life  and  to  modified  restoration  of 
functions.  Ulcerations  of  the  epiglottis,  of  the  arytenoid 
cartilages,  and  even  of  the  vocal  cords,  will  heal  with  almost 
marvellous  rapidity,  and  the  worst  result  to  be  anticipated  is 
some  slight  loss  of  comfort  in  deglutition,  or  a  permanently 
hoarse  voice. 

The  following  case  is  an  interesting  example  of  the  insidious 
mode  in  which  syphilis  may  attack  the  larynx ;  it  also  well 
illustrates  the  happy  results  of  treatment : 

Mrs.  O.,  set.  39,  married  eleven  years,  was  first  seen  on  March  8th,  1882,  on  account  of 
difficulty  and  pain  in  swallowing,  which  had  existed  for  ten  months.  At  first  the 
dysphagia  had  been  greatest  with  fluids;  now  solids  were  swallowed  not  only  with 
difficulty,  but  with  pain.  Her  voice  had  been  lost  for  five  months,  her  breathing  was 
somewhat  short  on  exertion,  and  she  was  troubled  with  distressing  cough  accompanied  by 
slightly  sanguineous  expectoration.  She  had  become  greatly  emaciated,  and  her  weight 
had  been  reduced  from  154  lb.  to  99  lb.  One  child  had  been  born  and  was  alive,  aged 
ID  years  ;  but  no  further  conception  had  occurred  until  about  four  years  previous  to  her 
visit.  Since  then  there  had  been  three  miscarriages.  The  patient  was  sent  to  me  as  the 
subject  of  either  phthisis  or  carcinoma,  but  with  the  laryngoscope  the  nature  of  the  case 
was  at  once  revealed  (Fig.  CXXXIV.).  Not  only  was  the  whole  larynx  greatly  swollen, 
but  the  epiglottis  was  both  thickened  and  inflamed  in  an  intense  degree.  Fully  a  third  of 
this  valve  had  been  destroyed,  and  the  ulcerative  process  was  still  advancing.  The 
patient  was  at  once  ordered  15  grains  of  iodide  of  potassium  with  10  grains  of  bromide 
of  potassium  three  times  daily,  and  frequent  steam  inhalations  of  benzoin  and  chloroform 
(Form.  30).    The  solid  nitrate  of  silver  was  applied  daily,  for  ten  days,  to  the  ulcerated 


DISEASES  OF  THE  THROAT  AND  NOSE. 


siuTace  with  the  aid  of  the  laryngeal  mirror  ;  when  the  destructive  process  being 
checked,  a  solution  of  sulphate  of  copper  (Form.  6i)  was  substituted  locally,  and 
biniodide  of  mercury  was  given  internally.  In  forty  days  the  larynx  had  assumed  the 
appearance  depicted  in  Fig.  CXXXV.    The  patient  could  eat  well,  and  had  gained  9  lb. 


Figs.  CXXXiV.  and  CXXXV.— Tertiary  Svpiiilitic  Ulceration  of  the 

Larynx. 

[The  first  drawing  represents  the  condition  on  commencement  of  treatment ;  the  second 

five  weeks  later.] 

in  weight.  The  after-history  was  one  of  continued  improvement,  under  modified 
mercurial  treatment,  and  six  months  later  she  had  further  recovered  flesh  so  that  the  scale 
indicated  142  lb.  A  very  interesting  feature  was  the  drawing  over  of  the  epiglottis 
towards  the  right  side,  an  effort  of  nature  to  overcome  the  gap  formed  by  the  ulceration. 

Treatment  :  General. — During  the  active  stage  of  ulcera- 
tion, the  administration  of  the  iodides  of  potassium  or  sodium 
(Form.  94)  is  in  the  highest  degree  beneficial.  Seeing,  also,  that 
the  majority  of  the  worst  cases  occur  in  very  poorly-fed  persons, 
cod-liver  oil  and  iodide  of  iron  are  of  great  therapeutic  value. 
In  other  cases  the  iodide  may  be  occasionally  remitted,  and 
cinchona  with  ammonia,  or  acid,  substituted.  Whenever  patients 
resist  the  iodides,  a  systematic  course  of  20  to  25  mercurial 
inunctions  should  be  employed.  When  the  ulcerations  are 
healed,  preparations  of  mercury  must  be  given  for  a  lengthened 
period,  as  prophylactic  against  future  attacks  (Form,  gi,  92). 

Local. — There  is  no  better  topical  remedy  for  syphilitic  ulcers 
than  nitrate  of  silver,  which  must  be  applied  daily  with  the  aid  of 
the  laryngoscope.  If  there  is  much  coating  of  secretion  over  the 
ulcer,  it  should  be  first  removed  by  means  of  a  soft  moist  brush, 
or  a  piece  of  absorbent  cotton-wool  in  a  suitable  holder. 

When  the  ulceration  is  of  the  epiglottis,  the  galvano-cautery 
acts  more  rapidly  in  arresting  the  destructive  process  than  even 
nitrate  of  silver. 

Laryngeal  oedema  must  be  met  by  the  prompt  performance  of 
tracheotomy,  unless  it  quickly  yields  to  medical  treatment. 
Tracheotomy  may  also  be  necessary,  at  least  as  preliminary  to 
later  measures,  if  stenosis  becomes  extreme. 


SYPHILITIC  LARYNGITIS. 


391 


The  tube  should  always  be  inserted  in  the  lowest  point  possible 
in  the  trachea,  and  should  on  no  account  be  removed,  however 
favourable  the  symptoms  may  appear,  unless  laryngoscopic  exami- 
nation give  evidence  that  the  physical  obstruction  is  lessened. 

At  a  very  early  period  after  tracheotomy  it  will  be  well  to  make 
an  opening  in  the  superior  surface  of  the  canula,  and  to  allow  the 
patient  to  wear  a  pea-valve,  so  as  to  favour  a  natural  process  of 
dilatation  by  means  of  the  current  of  air. 

It  is  well  to  warn  the  patient  on  whom  tracheotomy  has  been 
necessary  on  account  of  such  a  condition,  that  he  may  be  obliged 
to  retain  the  canula  for  the  rest  of  his  life. 

With  respect  to  the  further  treatment  of  cicatricial  stenosis,  it 
is  not  my  practice  to  invariably  perform  a  preliminary  tracheo- 
tomy as  is  counselled  by  Schroetter,  but  it  is  decidedly  advisable 
to  have  all  instruments  for  that  operation  ready  to  hand  whenever 
attempts  are  made  to  divide  a  cicatricial  web  by  a  cutting 
instrument,  or  to  dilate  the  narrowed  orifice  by  bougies  or  analo- 
gous measures  carried  on  through  the  natural  passage. 

Direct  treatment  of  membranous  stenoses  of  the  larynx,  what- 
ever their  nature,  by  surgical  means  is  very  tedious,  and  often 
very  discouraging ;  but  this  is  especially  the  case  when  the  web  is 
the  result  of  syphilis. 

Although  isolated  cases  more  or  less  successful  had  from  time 
to  time  been  reported,  even  in  pre-laryngoscopic  literature,  there 
can  be  no  doubt  that  to  Schroetter,  of  all  others,  is  due  the  merit 
of  perseverance  in  systematic  dilatation  by  means  of  tubes  and 
hollow  catheters  of  gradually  increasing  dimensions  passed  from 
above,  tracheotomy  having  been  previously  performed.  The 
tubes  are  directed  to  be  retained  in  position  for  from  fifteen  to 
thirty  minutes.  Schroetter  has  reported  several  successful  cases, 
and  others  have  occurred  in  the  practice  of  various  surgeons, 
especially  ^^Hering  of  Warsaw,  who  is  an  enthusiastic  follower  of 
Schroetter's  method,  and  has  contributed  a  valuable  essay  on  the 
subject.  The  process  is,  however,  very  slow,  and  involves  in  some 
instances  a  constant  treatment  of  eighteen  months  or  even  longer, 
and,  in  the  majority  of  cases,  the  wearing  of  a  canula  for  life. 
^^Stoerk  uses  a  dilator  which  is  attached  to  the  upper  part  of  a 
tracheotomy  tube,  distension  of  the  constriction  being  thus  made 
from  below  and  without  the  passage  of  any  instrument  by  the 
mouth.  i^Navratil  has  invented  an  elaborate  dilator  for  rapid  dila- 
tation, but  this  treatment  is  no  more  successful  in  the  larynx  than 
in  the  urethra,  and  is  attended  by  similar  risks  of  acute  inflamma- 
tion.     Whistler,  in  an  interesting  and  complete  monograph,  has 


392 


DISEASES  OF  THE  THROAT  AND  NOSE. 


drawn  attention  to  the  fact  previously  noticed  by  '^'^Liston  and 
^'Trendelenburg,  and  in  accordance  with  everyday  experience,  that 
long  retention  of  a  tracheotomy  tube  is  often  attended  by  a  certain 
amount  of  collapse  of  the  larynx,  and  by  atrophic  paralysis  of  the 
dilating  muscles  of  the  glottis.  Partly  on  this  account,  and  partly 
for  obtaining  more  permanent  results  than  are  usually  afforded  by 
simple  distension,  Whistler  '  devised  an  instrument  which  should 
combine  the  properties  of  a  knife  and  dilator  in  one.'  This 
laryngotome  (Fig.  CXXXVI.)  is  composed  of  an  almond-shaped 


D 


Fig.  CXXXVI. — Whistler's  Cutting  Dilator. 


dilator  (a)  within  which  is  a  concealed  blade  (c).  This  blade  is 
reversible,  so  that  it  may  divide  a  stricture  either  at  the  anterior 
or  posterior  commissure  of  the  larynx,  and  it  can  be  pushed 
forward  (b)  when  required  by  means  of  a  lever  attached  to  the 
handle  (d). 

I  have  myself  emplo3^ed  Whistler's  instrument  in  two  cases  ;  in 
both  there  was  considerable  improvement,  and  in  one  complete 
and  permanent  relief  The  following  are  the  chief  features  of  the 
first  case : 

Sarah  S.,  xt.  37,  married,  applied  at  the  hospital  on  April  27th,  18S5,  on  account  of 
loss  of  voice,  vvliich  had  existed  for  fifteen  months,  and  more  recently  a  sense  of  suflbca- 
tion  and  of  an  obstruction  in  the  throat  which  had  occasioned  some  difficulty  in 
swallowing. 

Her  family  history  showed  that  her  father  died  of  phthisis.  She  herself  had  had  five 
children,  three  of  whom  were  living  :  one  had  died  from  bronchitis,  and  one  as  the  result 
of  an  accident. 

Examination  of  the  larynx  (Fig.  CXXXVII.)  showed  an  inflammatory  cicatrix  along 
the  cushion  of  the  epiglottis,  and  a  tight  fibrous  band  uniting  the  vocal  cords  along  the 
anterior  two  thirds  of  their  free  border,  and  reducing  the  glottic  chink  to  the  size  of  a 
goose-quill.  The  left  vocal  cord  was  inflamed,  and  the  left  side  of  the  larynx  generally 
was  thickened.  Her  respiration  was  audibly  harsh  and  whistling,  but  regular  during  the 
day  ;  there  was  dyspnoea  on  slight  exertion,  and  at  night,  even  during  sleep,  there  was 
loud  inspiratory  stridor.  Slight  dulness  was  found  over  both  apices  of  the  lungs,  with 
prolonged  and  high-pitched  expiration.  She  had  lost  flesh  lately,  and  her  weight  on 
admission  was  96  lb.,  her  height  beine  about  5  feet  I  inch. 


SYPHILITIC  LARYNGITIS. 


393 


She  was  ordered  to  wear  a  Leiter  cold  coil  over  the  larynx,  to  inhale  benzoin  and 
chloroform  (Form.  30)  three  times  a  day,  and  to  take  lo  grains  of  iodide  and  bromide  of 
potassium  also  three  times  daily,  with  a  larger  dose  of  bromide  at  night.  Later  she  was 
ordered  nightly  inunctions  over  the  larynx  of  mercury  and  belladonna  ointment 
(Form.  79). 

Whistler's  dilator  was  employed  twice  a  week,  a  large  cotton-wool  probang  charged 
v\'ith  sulphate  of  copper  being  passed  through  the  constriction  on  intervening  days. 


Figs.  CXXXVII.  and  CXXXVIII.— Cicatricial  Stenosis  bei-ork  Treatment. 
The  Same  after  Use  of  Cutting  Dilator. 

The  improvement  in  her  larynx  in  six  months  is  represented  by  Fig.  CXXXVIII,  At 
this  time  her  voice  had  returned,  but  was  still  hoarse.  Her  breathing  was  easy  and  quiet, 
both  night  and  day.  She  had  gained  in  strength  and  in  weight,  and  continued  to  attend 
from  time  to  time  as  an  out-patient.  , 

Although  in  this  case  there  was  no  direct  history  of  syphiHs,  the 
result  of  treatment  leaves  little  doubt  as  to  the  nature  of  the 
trouble. 

Being  of  opinion  that  the  difficulties  of  passing  tubes  into  the 
larynx,  and  especially  through  a  cicatricial  stricture,  are  much 
greater  than  is  generally  stated,  I  have  had  constructed  an  instru- 
ment which  combines  the  advantages  of  the  hollow  tube  of 


Fig.  CXXXIX.— Author's  Hollow  Laryngeal  Dilator  with  Cutting  Blade 
(One-third  Measurements), 
a,  terminal  of  the  hollow  dilator,  containing  the  cutting  blade  (b),  the  extent  of  which 
is  regulated  by  the  screw  at  D.    e  e  show  openings  for  passage  of  air. 

Schroetter  and  the  cutting  dilator  of  Whistler.  Thus  the  surgeon 
while  always  sure,  by  the  outward  passage  of  air,  when  the  hollow 
instrument  is  in  the  larynx,  is  able  to  incise  with  more  certainty 
as  to  what  he  is  cutting,  and  moreover  in  case  of  spasm  the  air- 
passages  are  not  entirely  obstructed.    This  instrument,  which  is 


394 


DISEASES  OF  THE  THROAT  AND  NOSE. 


figured  above,  requires  no  description.  It  is  no  longer  than 
Whistler's,  and,  like  his,  the  cutting-edge  of  the  blade  is  made 
reversible  ;  in  addition,  the  amount  of  blade  can  be  regulated  by 
the  screw  at  D.  The  instrument  has  been  used  with  satisfactory 
results  in  the  later  stages  of  the  case  reported  at  page  312. 

Unsatisfactory  though  the  results  of  cutting  and  dilatation  of 
chronic  laryngeal  and  tracheal  stenosis  undoubtedly  are,  I  am 
fully  in  accord  with  Whistler  that  medication  by  drugs  is  entirely 
useless  ;  though  in  the  case  of  recent  stenosis — glottic  or  subglottic 
— iodides  and  mercury  occasionally  give  good  results. 

Where  dilatation  failed,  I  would  certainly  prefer  a  tracheotomy 
to  resection  of  a  portion  of  the  larynx  as  practised  by  Heine, 
Bruns,  and  others. 

There  are  two  stages  of  syphilitic  laryngitis  —  I  might  add 
tracheitis — in  which  the  question  of  tracheotomy  has  to  be  con- 
sidered. The  first,  that  of  acute  oedema,  which  is  so  common  an 
occurrence  in  the  earlier  tertiary  period.  This  oedema  may  occur 
during  the  ulcerative  process,  or  it  may  be  due  to  development  of 
a  gumma,  or  to  perichondritis,  and  will  often,  as  has  already  been 
indicated,  be  reduced  by  prompt  and  appropriate  constitutional 
measures,  and  in  no  disease  will  the  surgeon  who  uses  the  laryn- 
goscope both  intelligently  and  diligently  have  more  gratifying 
reward  for  patient  watching  and  perseverance  in  treatment.  Of 
such  a  fact  the  experience  of  all  specialists  will  afford  example. 

I  will  mention  one  of  several,  in  which  a  patient — I  need  hardly  say  a  hospital  one, 
for  private  patients  are  seldom  so  constant — has  attended  me  weekly  or  fortnightly  for 
about  fifteen  years.  Twice  he  has  been  taken  to  a  general  hospital  and  threatened 
tracheotomy,  but  he  has  been  now  free  from  acute  attacks  for  nearly  ten  years.  He  is 
the  subject  of  more  or  less  glottic  stenosis,  for  which  he  is  treated  by  the  passage  of 
a  large  cotton  wool  brush,  charged  with  a  solution  of  sulphate  of  copper. 

Supposing  a  tracheotomy  to  be  called  for  in  such  a  case  of 
oedema,  there  is  a  reasonable  hope  that  the  tube  may  shortly  be 
dispensed  with.  A  pea-valve  may  always  be  very  early  employed, 
and  the  sooner  an  orifice  is  made  in  the  upper  aspect  of  the  tube 
the  better. 

Some  years  ago  I  saw  in  consultation  and  assisted  in  the  operation  and  treatment  of  a 
colonel  in  the  army,  under  the  care  of  Mr.  Nunn,  in  which  case,  after  three  months  and 
for  a  period  of  nine,  the  patient  gave  the  word  of  command  with  the  tube  in  his  throatj 
and  was  enabled  to  dispense  with  it  permanently  at  the  end  of  a  year. 

The  second  phenomenon  in  the  course  of  a  syphilitic  laryngitis, 
for  which  tracheotomy  is  indicated,  is  that  of  stenosis,  and  this 
is  usually  infra-glottic  in  position.  It  occurs  at  a  quite  late  period, 
ten,  fifteen,  twenty,  or  even  thirty  years  after  primary  infection. 


SYPHILITIC  LARYNGITIS. 


395 


and  is  due  either  to  deforming  cicatrices  or  to  the  deposit  of 
fibroid  tissue  at  situations  not  necessarily  the  seat  of  previous 
ulceration.  Without  doubt  these  cases  are  becoming  less 
frequent,  and  will  become  still  more  rare,  as  the  use  of  the  laryn- 
goscope and  topical^  laryngeal  medication  becomes  more  general. 
They  are  at  the  present  day  much  more  uncommon  in  the  United 
Kingdom  than  in  Austria-Hungary  and  Poland  :  whether  this  cir- 
cumstance is  due  to  causes  racial,  climatic,  hygienic,  or  dietetic — 
I  speak  more  especially  of  the  use  of  raw  spirits — is  not  now 
question  to  be  considered ;  but  it  is  important  to  note  that  the 
treatment  adopted  also  differs  essentially,  or  at  least  yields  very 
different  results.  I  suppose  few  of  us  can  claim  many  such  cases 
of  sub-glottic  and  tracheal  stenosis  as  are  reported  by  Schroetter 
of  Vienna,  Navratil  of  Buda-Pesth,  or  Heryng  of  Warsaw.  I 
confess  that  I  have  seldom  had  a  case  in  which  attempts  at 
mechanical  dilatation,  without  cutting,  have  not  rather  increased 
the  distress  and  precipitated  the  tracheotomy  by  promoting  suf- 
focative spasms  of  a  serious  grade  ;  nor  have  I,  after  opening  the 
windpipe,  been  much  encouraged  to  persevere  in  mechanical  dilata- 
tion with  any  hope  of  being  able  to  remove  the  tracheotomy  tube. 
I  believe  it  to  be  better — certainly  more  humane — surgery  when- 
ever we  are  convinced  that  there  is  an  obstinate  stenosis  due  to 
syphilis,  to  perform  an  early  tracheotomy,  and  to  advise  a  life-long 
retention  of  the  tube.  I  have  only  to  add  that  the  lower  the 
tracheotomy  can  be  made  in  such  a  case  the  better,  for  nothing  is 
more  deceptive  than  the  apparent  high  situation  of  a  stenosis  as 
viewed  by  the  mirror,  and  nothing  more  distressing  than  the  dis- 
appointment so  frequently  experienced  of  finding  that  our  tube 
has  not  reached  the  stricture,  or  if  it  has  relieved  an  upper  one, 
its  introduction  has  been  rendered  useless  by  the  existence  of 
another  at  a  lower  level. 

^'^O'Dwyer  has  reported  five  cases  in  which  it  has  been  serviceable 
in  the  adult.  His  tubes  for  the  purpose  are  constructed  of  metal, 
similar  to  those  for  children,  the  large  ones  of  vulcanite,  and  they 
have  been  worn  for  periods  varying  from  a  few  days  to  several 
months — in  one  case  ten.  Deglutition  is  comparatively  easy  after 
the  first  day  or  two.  Dr.  O'Dwyer  kindly  gave  me  the  first  in- 
struments he  had  made  for  this  purpose,  and  I  have  employed 
the  method,  with  encouraging  results,  in  two  cases. 

*'  The  word  *  topical '  is  emphasized  here  because  while  I  am  ready  to  admit  that 
many  cases  of  syphiHtic  inflammation  and  ulceration  in  the  larynx  can  be  healed  by 
appropriate  general  treatment  alone,  it  is  only  by  carefully  directed  topical  applications 
that  deforming  cicatrization  so  generally  the  result  of  the  healing  process  can  in  any 
degree  be  controlled. 


396 


DISEASES  OF  THE  THROAT  AND  NOSE. 


In  some  cases  the  contraction  is  in  the  trachea,  and  is  seldom 
then  within  reach  of  the  surgeon.  Such  a  condition  may  be  due  to 
compression  by  enlarged  thyroid  or  other  glands,  by  an  aneurism, 
or  other  new  formation,  or  may  be  caused  by  interstitial  thicken- 
ing, of  which  the  two  principal  causes  are  syphilis  and  rhino- 
scleroma.  In  the  former  cases,  while  incision  is  contraindicated^ 
dilatation  is  useless,  and  even  dangerous  ;  in  any  circumstance, 
division  is  sure  to  be  followed  by  but  very  partial  and  temporary 
relief. 

CONGENITAL  SYPHILIS  OF  THE  LARYNX. 

In  my  remarks  on  *  Congenital  Syphilis  in  the  Pharynx ' 
(p.  209),  I  have  referred  to  the  classical  essay  of  ^^John  N. 
Mackenzie  as  the  first  means  of  attracting  attention  to  this  im- 
portant and  hitherto  unexplored  subject;  but  independently  of  that 
circumstance,  it  will,  on  its  own  merits,  always  stand  as  a  per- 
manently valuable  addition  to  our  knowledge  of  laryngeal  disease, 
and,  as  such,  it  will  repay  for  careful  perusal.  There  is  doubtless 
much  force  in  the  conviction  of  this  author,  *  that  laryngeal 
lesions  (in  connection  with  congenital  syphilis)  have  not  been 
found  more  frequently,  simply  because  they  have  not  been 
sought ;'  but  I  am  bound  to  say  that  in  the  seven  years  which 
have  elapsed  since  his  article  was  written,  the  joint  experience  of 
my  colleagues  and  myself  has  failed  to  confirm  his  postulate 
'  that  laryngeal  disease  is  not  rare  in  congenital  syphilis ;  that  it 
is  one  of  the  most  constant  and  characteristic  of  its  pathological 
phenomena ;  and  that  we  may  look  for  invasion  of  the  larynx 
with  as  much  confidence  in  the  congenital  as  in  the  acquired 
form  of  the  disease.' 

On  the  contrar}^,  while  readily  conceding  that  many  cases  of 
chronic  superficial  laryngitis^  as  well  as  of  relapsing  tracheal  and 
hronchial  affections  in  infantile  life,  are  much  more  often  associated 
with  the  syphilitic  dyscrasia  than  is  generally  suspected,  we  do 
not  see  chronic  interstitial  laryngitis,  nor  deep,  destructive,  ulcerative 
laryngitis,  as  ordinary,  frequent,  or  in  any  sense  typical  evidences 
of  congenital  syphilis ;  though  cases  exhibiting  characteristic 
appearances  in  the  palate  and  naso-pharyngeal  regions,  whether 
as  early  or  tardy  evidences  of  congenital  syphilis,  are  of  almost 
daily  occurrence  in  our  practice. 

Monti  states  that  he  has  twice  seen  laryngeal  syphilis,  which 
arose  during  intra-uterine  life ;  but,  looking  at  the  absolutely 
passive  part  played  by  the  organs  of  respiration  previous  to  birtli, 
such  a  circumstance  must  be  very  rare,  and  the  same  may  be 
said  of  so-called  congenital  webs,  h3^perplasi8e,  and  papillomata 
in  the  larynx  and  trachea. 


SYPHILITIC  LARYNGITIS. 


397 


It  is  admitted  by  John  Mackenzie  that  'the  classification  of 
the  laryngeal  lesions  of  congenital  syphilis  with  secondary  and 
tertiary  will  not  obtain  as  in  the  case  of  acquired  disease and 
in  this  respect  they  correspond  with  what  we  find  in  the  pharynx, 
deep  destructive  forms  of  ulceration  being  not  infrequently  the 
first  indications  of  specific  mischief  in  either  region. 

Age  is  an  important  factor  both  of  etiology  and  prognosis.  Two- 
thirds  of  the  cases  reported  occurred  within  the  first  year  of  life ; 
and  as  to  the  issue,  the  younger  the  patient  the  more  certainly 
and  rapidly  fatal  is  the  malady.  Diagnosis  must  generally  depend 
on  correct  recognition  of  functional  symptoms.  The  voice  and  cry 
exhibit  all  grades  of  phonetic  impairment  from  slight  huskincss 
to  the  toneless  whisper  of  absolute  aphonia,  with  a  resulting 
chronic  and  permanent  hoarseness.  Cough  is  frequent,  raucous, 
and  paroxysmal,  and  is  unaccompanied  by  much  expectoration. 
Respiration  is  seriously  embarrassed,  and  deglutition  is  often 
difficult,  and  may  be  painful.  Laryngismus  is  noted  by  John 
Mackenzie  as  a  not  infrequent  result  of  congenital  syphilitic 
laryngitis.  These  symptoms  may  to  some  extent  be  caused  by 
pharyngeal  mischief ;  and  there  may  also  be  concurrent  cutaneous 
manifestations. 

In  the  absence  of  objective  verification,  laryngoscopic  examina- 
tion should  always  be  attempted,  and  is  not  seldom  successfully 
effected  by  the  expert. 

I  was  recently  enabled  to  see  and  to  demonstrate  the  larynx  of 
a  child,  aged  only  8  months,  whom  I  saw  in  consultation  with 
Dr.  Macfee,  of  Limehouse. 

In  any  case  exhibiting  the  symptoms  thus  most  cursorily 
sketched,  we  need  not  waste  time  in  seeking  for  confirmation  of 
our  diagnosis  by  attempts  to  elicit  corroborative  evidence  from 
the  parents,  but  should  at  once  attempt  a  treatment  which  will 
be  happily  efficient  if  the  case  is  specific,  and  is  at  least  harmless 
if  that  dyscrasia  is  wanting.  Local  mercurial  inunction  over  the 
larynx,  the  administration  of  grey  powder  in  small  and  frequent 
doses,  and,  where  the  symptoms  are  acute,  vigorous  administra- 
tion, even  to  iodism,  of  the  iodides  of  potassium  or  sodium,  are 
the  measures  on  which  we  must  rely.  If  the  naso-pharyngeal 
region  is  obstructed,  nasal  douches  of  boracic  acid,  and  the 
passage  of  a  brush  through  the  inferior  meatus,  will  often  greatly 
relieve  respiration ;  but  should  all  our  efforts  not  be  attended  by 
prompt  and  sensible  benefit,  I  fully  agree  with  John  Mackenzie 
that  early  tracheotomy — that  is,  within  forty-eight  hours  from  the 
first  onset — is  to  be  advocated.  It  is  probable  that  intubation 
would  be  attended  by  success  in  this  class  of  case. 


39B 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Wherever  infantile  laryngitis  occurs  in  a  syphilitic  subject,  re- 
currence is  to  be  apprehended  on  very  slight  aggravating  causes. 
All  measures  of  prophylaxis  as  to  exposure  to  damp  and  cold 
must,  therefore,  be  rigorously  enforced  for  the  first  seven  or  eight 
years  of  life,  and  constitutional  medical  treatment  be  systema- 
tically pursued. 

REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO, 

380 

I 

380 

2 

380 

3 

380 

4 

380 

5 

381 

6 

381 

7 

382 

8 

387 

9 

387 

10 

391 

II 

391 

12 

391 

13 

391 

14 

391 

15 

392 

16 

392 

17 

395 

18 

396 

19 

396 

20 

NAME. 


Gerhardt. 
Lewin, 

WiLLlGK. 

Gerhardt  and  Roth, 
sommekbrodt. 

Morell-Mackenzie. 


Whistler. 
Mandl. 

TURCK. 

Schroetter. 

Hering. 

Stoerk. 

Navratil. 

Whistler. 

LiSTON. 

Trendelenburg. 

O'DWYER. 

John  N.  Mackenzie. 
Monti. 


TITLE  OF  WORK  REFERRED  TO. 


Virchow's  Arc/nv,  Bd.  xxxi.,  Heft  I.  }S6i. 
Die  Behandhmg  der  Syphilis.   Berlin,  1869. 
Prager  Vierteljahrschrlft,  vol.  ii.  1S56. 
Virchow's  Archiv,  Bd.  xxxi.,  Heft  i.  1861. 
Wiener  Med.  Presse,  Ko.  20.  1870. 

j  Reyjiolds'  System  of  Medicine^  vol.  iii. 

{     London,  1868. 

(  Manual  of  Diseases  of  Throal,  vol.  i., 
I     p.  352.  1880. 

f  Lectures  on  Syphilis  of  the  Larynx,  p.  60. 

\     London,  1879. 

Op.  cit.,  p.  700. 

Op.  cit.,  p.  388  et  seq. 

j  Beitrag  zur  BeJiandhing  der  L.arynx- 
(     stenosen.    Wien.  1876. 
\  Trans.  Lnternat.  Med.  Congress,  vol.  iii., 
j     p.  242.  1881. 

Wien  Med.  Wochenschr.,  No.  46.  1879. 
Lary7igol.  Beitrag.  1874. 
Notes  on  Syph ilitic Strictures.  Lond on  ,1881. 
Elements  of  Stirgej-y.    London,  1 831. 
Langenbeck's^/r/zzV,  vol.  xiii.,  p.  335.  1872. 
Trans.  Ljiternat.  Med.  Congress.  1887. 
Amer.  Journal  of  Med.  Sciences,  p.  321 
et  seq.    October,  1880. 
\  Philatielphia    ]\Leiical    Times,  p.  336. 
)     April  28,  1877. 


CHAPTER  XIX. 


TUBERCULOUS  LARYNGITIS. 

(Figs.  68  to  76,  Plate  VIII.  ;  Figs.  lor,  104,  and  105,  Plate  XI.  i 
and  Figs.  106,  107,  and  108,  Plate  XII.) 

Synonyms. — Laryngeal  phthisis  ;  Throat  consumption. 

'  That  evidence  of  the  tubercular  diathesis  influences  a  local 
laryngeal  inflammation  in  a  manner  eminently  characteristic,  and 
at  a  period  long  prior  to  the  discovery  of  equally  well-marked 
symptoms  in  the  lungs,  is  a  fact  which  the  daily  observation  of 
those  engaged  in  laryngeal  practice  establishes  as  incontrovertible. 
Whether  or  not  there  be  tubercle  actually  developed  in  the  larynx, 
or  what  indeed  is  the  nature  of  tubercle  wherever  developed,  the 
author  does  not  presume,  and  indeed  does  not  care,  to  decide. 
Seeing,  however,  that  tuberculosis  is  a  disease  primarily  mani- 
festing itself  more  especially  in  the  respiratory  organs  ;  seeing 
that  catarrh  is  one  of  the  most  frequent  excitants  to  that  disease, 
and  that  many  catarrhal  inflammations  of  the  lungs  commence  in 
the  larynx,  it  is  at  least  fair  to  infer  that,  in  those  cases  in  which 
the  eye  reveals  what  has  come  to  be  recognised  as  tuberculous 
laryngitis  before  the  ear  detects  the  presence  of  tubercle  in  the 
lungs,  the  disease  has  primarily  attacked  the  former  organ.  Not 
only  so,  but  noting  also  that  the  morbid  changes  in  the  larynx,  as 
physically  evidenced  in  every  stage,  are  quite  difterent  from  those 
of  simple  catarrhal,  and  of  syphilitic,  to  say  nothing  of  exanthe- 
matous  and  other  phlegmonous  inflammations,  it  is  not  unreason- 
able to  suggest  that  the  factors  are  also  of  an  equally  distinctive 
character. 

*  It  is  quite  certain  that  the  pale,  opaque  tumefaction  of  the 
arytenoid  cartilages  and  of  the  epiglottis  in  laryngeal  phthisis  has 
not  the  clear  transparency  of  serous  oedema,  the  active  glandular 
inflammation  of  simple  laryngitis,  the  hyperplastic  infiltration  oi 
syphilis,  or  the  angry  inflammatory  irritation  of  carcinoma.  Nor 


400  DISEASES  OF  THE  THROAT  AND  NOSE. 

is  the  consequent  ulcerative  process  less  distinctive  ;  there  is  no 
erosion,  nor  deep  excavated  circumscribed  ulcers,  followed  by 
narrowing  cicatrices  ;  nor  new  formations  taking  on  an  ulcerative 
process,  but  a  true  carious  degeneration,  causing  loss  of  tissue, 
which,  commencing  superficially  at  small  points,  leads  to  universal 
destruction  of  the  deeper  parts,  without  extension  to  neighbouring 
glands,  and  with  but  feeble,  if  any,  attempt,  under  treatment,  at 
a  reparative  process. 

*  It  is,  therefore,  surprising  that  we  should  be  told,  with  refer- 
ence to  laryngeal  phthisis,  on  the  one  hand,  that  "  tubercle  appears 
to  play  a  very  secondary  part,  if  any  part  at  all,"  in  its  production 
(Mackenzie) ;  and  on  the  other,  "  that  neither  the  catarrh  nor  the 
ulceration  of  phthisical  subjects  presents  any  characteristic  signs 
by  which  it  could  be  recognised  as  such,  [and  that]  the  attempts 
made  to  establish  pathognomonic  peculiarities  cannot  be  said  to 
have  succeeded"  (Von  Ziemssen). 

'  We  prefer  to  adopt  the  view  of  Virchow,  who  just  exactly 
recommends  the  larynx  as  the  most  appropriate  place  for  the 
study  of  true  tubercle.' 

The  foregoing  words,  with  which  I  commenced  this  chapter  in 
my  former  edition,  were  written  nearly  ten  years  ago.  Three 
years  later,  in  conjunction  with  ^Dr.  Dundas  Grant,  I  reported 
amongst  others  two  cases  which  illustrated  the  probability  that 
the  throat  can  be  attacked  primarily  with  tubercle.  One  was 
entitled  *  Tuberculous  ulceration  of  the  tongue  two  years  and  a 
half  prior  to  laryngeal  or  pulmonary  manifestations ;'  the  other, 
*  Tuberculous  disease  of  the  gums  and  fauces  nearly  three  years 
prior  to  laryngeal  or  pulmonary  evidences ;'  but,  as  we  then  stated, 
the  fact  that  there  can  be  tuberculous  disease  in  either  pharynx  or 
jarynx  could  not  be  definitely  settled  until  an  opportunity  should 
arise  of  dissecting  subjects  of  tuberculosis  in  the  throat  in  whom 
there  were  no  evidences  of  disease  in  the  chest.  Since  that  time 
this  event  has  occurred,  ^j^enin^e  h^s  reported  the  case  of  a  bo}-, 
aged  four  and  a  half  years,  who  died  of  tubercular  meningitis ; 
the  necropsy  showed  the  presence  of  laryngeal  ulceration  zciih 
tnherck  bacilli,  the  thoracic  and  abdominal  organs  being  at  the 
same  time  free  from  tubercular  disease.  Many  other  cases  similar 
to  our  own  in  which  such  a  condition  was  suspected  have  also 
been  recorded  ;  and  it  may  now  be  considered  as  an  accepted 
fact  that  primary  tubercular  disease  may  not  only  attack  the 
larynx,  but  may  even  cause  death,  without  the  lungs  becoming 
affected. 

We  may  therefore  for  the  future  consider  tuberculosis  of  the 


TUBERCULOUS  LARYNGITIS. 


401 


larynx  as  a  primary  disease,  to  be  studied  with  equal  interest  from 
the  aspects  of  pathology,  diagnosis,  prognosis,  and  therapeutics. 
Notwithstanding,  I  do  not  for  a  moment  contend  that  laryngeal 
phthisis  is  not  generally  secondary ;  nor  must  it  be  forgotten  that 
in  tuberculous  patients  a  laryngitis  may  occur  which  is  non- 
tuberculous — that  is  to  say,  one  which  does  not  depend  upon  the 
presence  of  tubercle  in  the  larynx — and  such  a  laryngitis  offers 
little  to  distinguish  it  from  an  ordinary  inflammation,  except  that 
it  is  less  amenable  to  treatment. 

^Beverley  Robinson,  in  an  able  paper,  insists  on  the  wow-tuber- 
culous and  essentially  catarrhal  character  of  '  the  very  large 
majority,  if  not  all,  of  the  laryngeal  conditions  which  are 
encountered  in  pulmonary  phthisis,  and  which  have  a  more  or 
less  direct  relationship  with  the  march  of  the  disease  in  the 
lungs.'  In  this  view  he  is  opposed  to  most  observers  on  this  side 
of  the  Atlantic,  and  to  many  of  his  own  countrymen ;  but  there  is 
much  force  in  the  arguments  he  adduces  in  favour  of  the  probably 
greater  frequency  of  purely  catarrhal  conditions  of  the  larynx  in 
American  subjects  of  pulmonary  tuberculosis.  In  this  connection 
it  is  to  be  remarked  that  considerable  differences  exist  in  the 
characters  of  many  other  laryngeal  diseases  in  different  countries. 
Laryngeal  neoplasms,  for  example,  are  probably  more  frequent 
in  France  than  in  England  ;  and  my  own  experience  is  decidedly 
in  favour  of  chronic  stenosis  of  the  larynx  being  much  rarer  in 
this  country  than  it  is  in  Austria,  Hungary,  and  Poland. 

A  case  recently  occurred  in  the  hospital  practice  of  my  colleague,  Dr.  Orwin,  in  which 
there  was  extensive  tuberculous  destruction  of  the  soft  palate.  On  post-mortem  examina- 
tion the  lungs  were  likewise  seen  to  be  profoundly  diseased,  but  with  the  exception  of 
slight  thickening  of  the  epiglottis  the  larynx  was  free  from  any  tuberculous  implication. 

•^Gottstein  also  quotes  an  instructive  example  of  a  very  similar 
character  in  illustration  of  the  non-tubercular  nature  of  inter- 
current laryngeal  catarrh  during  the  progress  of  a  case  of  pul- 
monary consumption.  The  patient  was  a  member  of  his  own 
family  who  died  of  phthisis  : 

So  long  as  the  pulmonary  symptoms  were  slight,  he  suffered  from  repeated  attacks  of 
obstinate  laryngeal  catarrh  with  aphonia.  Though  the  pulmonary  disease  advanced,  the 
larynx  remained  unaffected  up  to  the  time  of  death,  while  a  tubercular  otitis  and  tuber- 
cular ulceration  of  the  septum  of  the  nose,  which  resulted  in  perforation,  developed. 

Tuberculous  laryngitis  is  seen  in  both  the  acute  and  chronic 
forms.  The  first  is  generally  due  to  exposure  to  the  ordinary 
causes  of  inflammation,  and  may  be  primary ;  the  second  is 
always  secondary  to  other  manifestation  of  the  dyscrasia. 

26 


402 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Etiology. — The  predisposing  causes  are  those  which  favour 
active  growth  of  the  tubercle  bacillus  in  other  situations.  There 
is  the  invariable  element  of  a  low  state  of  vitality,  either  hereditary 
or  acquired,  with  a  resulting  feebleness  of  recuperative  power. 
Those  exposed  to  catarrhal  influences  are  more  liable  to  have  the 
larynx  primarily  attacked.  We  thus  find  it  much  more  frequent 
in  the  male  sex  than  in  the  female,  the  proportion  being  as  three 
to  one.  As  a  further  proof  of  the  importance  of  this  factor,  tem- 
porary improvement  is  often  found  to  take  place  in  summer  or  on 
favourable  change  of  residence,  this  result  being  more  constant 
and  pronounced  in  the  larnygeal  than  in  the  pulmonary  form  of 
the  disease.  Experience  does  not  seem  to  prove  that  functional 
activity  is  by  any  means  an  invariable  predisponent,  but  there  are 
sufficient  cases  on  record  to  illustrate  the  occasional  occurrence  of 
such  a  cause,  and  we  have  personal  experience  of  a  failure  of 
voice  in  the  person  of  professional  *  voice-users,'  as  clergymen, 
teachers  and  auctioneers,  as  the  forerunner  of  local  manifestation 
of  tuberculosis  in  the  larynx.  On  the  other  hand,  any  cause  for 
debility  of  the  general  system  (as,  for  example,  in  women, 
amenorrhoea,  or  other  uterine  disturbance),  which  leads  to  the 
production  of  the  so-called  functional  or  nervous  aphonia,  is, 
quite  independently  of  professional  use  of  the  voice,  a  not  un- 
common premonitor  of  throat  consumption.  In  such  a  case 
there  will  appear  no  disease  in  the  larynx  beyond  a  loss  of 
adductive  power  in  the  vocal  cords,  and  some  paleness  of  the 
mucous  membrane,  explained  by  the  general  condition  ;  while 
the  lungs,  although  insufficiently  expanded,  and  of  somewhat 
diminished  resonance,  may  be  pronounced  free  from  disease. 
Local  treatment  of  the  larynx  by  stimulating  inhalations  and 
by  faradization  may  restore  the  voice,  which  is,  however,  soon 
lost  again.  Tonics,  change  of  air  and  of  scene,  are  of  no  avail, 
and  at  a  period  varying  from  a  few  months  to  perhaps  a 
couple  of  years,  undoubted  phthisical  symptoms  develop  them- 
selves. 

As  to  the  frequency  of  laryngeal  tuberculosis  and  its  relation  to 
pulmonary  disease  of  the  same  nature,  ^Heinze  in  his  exhaustive 
monograph  states  that  among  4,486  consecutive  autopsies  made 
at  the  Pathological  Institute  of  Leipzig,  pulmonary  phthisis  was 
the  cause  of  death  in  1,226  instances,  and  of  these  5i'3  per  cent, 
had  ulcerations  in  the  larynx.  He  says  further,  and  this  is  of 
great  interest  in  connection  with  our  present  subject,  that  ulcera- 
tions were  never  found  with  iuhercidosis  of  other  organs  when  the  kings 
were  intact.    We  have  already  recorded  an  exception  to  this  state- 


TUBERCULOUS  LARYNGITIS. 


403 


ment  in  the  experience  of  Demme,  and  it  remains  to  be  seen 
whether  that  exception  may  not  in  time  become  somewhat  less 
exceptional. 

As  to  the  influence  of  sex  and  age  in  laryngeal  tuberculosis, 
Heinze's  statistics  agree  in  general  with  those  of  Willigk,  Ziemssen, 
and  others;  as  to  the  first,  the  proportion  of  males  to  females 
attacked  by  the  disease  is  as  near  as  possible  as  three  to  two  ; 
in  regard  to  age,  the  maximum  frequency  exists  in  individuals 
between  twenty-one  and  thirty  years  of  age,  the  minimum  under 
one  year. 

Pathology. — Tubercle  in  the  larynx  is  histologically  identical 
with  the  same  structure  wherever  else  it  may  occur,  and  consists 
of  a  mass  of  small  cell  inflammatory  tissue,  which  is  (according  to 
some  observers)  held  together  by  a  filamentous  network,  and 
encloses  what  is  known  as  a  giant  cell,  the  whole  presenting,  more 
or  less,  indications  of  a  degenerative  process  at  the  centre,  whilst 
it  spreads  at  the  periphery,  with  destruction  of  the  tissue  which  it 
invades.  However  divided  opinions  may  be  respecting  the  micro- 
organisms of  other  specific  diseases,  there  is  no  longer  any  doubt 
whatever  of  the  existence  and  specific  nature  of  a  bacillus  tuber- 
culosis, the  ever-memorable  discovery  by  Koch  in  1882  having 
been  since  confirmed  by  all  bacteriologists.  Nevertheless,  says 
Koch,  *  up  to  the  present  the  evidence  of  bacilli  in  the  sputum  has 
been  considered  rather  as  an  interesting  point  of  secondary 
importance,  which,  while  it  may  make  diagnosis  more  certain,  is 
often  neglected  on  the  ground  that  it  does  not  help  the  patient  in 
any  way.'  There  are  even  a  few  physicians  who,  granting  the 
facts,  decline  to  accept  the  inevitable  deductions  therefrom. 

Granted,  however,  that  the  baciUus  is  always  present  in  a  case 
of  tuberculosis,  it  does  not  necessarily  follow  that  it  should  be 
found  in  the  sputum  in  every  instance  in  which  the  respiratory 
tract  is  involved.  Moreover,  as  ^^Hunter  Mackenzie  has  said,  'its 
prognostic  value  cannot  be  determined  with  accuracy,  inasmuch 
as  it  may  be  as  abundant  in  a  comparatively  slow  non-febrile 
case  as  it  is  in  a  more  acute  and  febrile  one.'  These  conclusions 
are  in  exact  accordance  with  the  results  of  the  examinations  for 
the  bacillus,  which  have  for  some  time  been  systematically 
pursued,  in  every  case  of  even  suspected  phthisis  that  has 
occurred  in  our  hospital  practice. 

The  tuberculous  process,  as  witnessed  in  the  larynx,  is 
characterized  by — (i)  Anaemia ;  (2)  Infiltration  and  tume- 
faction ;  (3)  Ulceration ;  (4)  Necrosis  or  caries ;  (5)  New  for- 
mations. 


404 


DISEASES  OF  THE  THROAT  AND  NOSE, 


1.  Anaemia. — I  was  formerly  inclined  to  look  on  '  a  very  decided 
and  general  pallor  of  the  larynx  '--to  quote  the  words  of  ^Sawyer — ■ 
as  a  much  more  constant  indication  of  early  local  changes  than 
I  have  with  further  experience  found  to  be  the  case,  and  there  are 
undoubtedly  a  considerable  number  of  instances  in  which  the 
disease  begins  with  a  hyperaemia.  The  explanation  of  these 
apparently  contradictory  conditions  is  afforded  by  Cohen,  who 
says,  '  The  earliest  recognisable  stage  of  the  acute  form  is  almost 
always  manifested  by  marked  congestion  of  the  mucous  membrane. 
The  earliest  recognisable  stage  of  the  chronic  and  much  more 
frequent  form,  is  almost  always  manifested  by  marked  pallor  of 
the  mucous  membrane.' 

2.  Infiltration  and  Tumefaction. — This  may  be  considered  the 
first  invariable  characteristic  of  laryngeal  tuberculosis  ;  it  may  be 
general,  but  is  much  more  frequently  partial.  The  general  seat 
of  earliest  infiltration  is  the  inter-arytenoid  space,  the  coverings 
of  one  or  both  of  the  arytenoid  cartilages,  and  the  ary-epiglottic 
folds  ;  but  I  have  often  seen  swelling  of  the  epiglottis  itself  pre- 
cede any  other  local  change,  while  in  patients  whose  profession 
involves  much  exercise  of  the  voice  the  swelling  may  first  be  seen 
in  the  vocal  cords  and  ventricular  bands.  The  tumefaction  is  by  no 
means  generally  caused  by  true  serous  oedema,  although  it  presents 
many  characters  thereof,  but  it  is  due  to  tuberculous  infiltration 
in  the  sub-epithelial  layer  of  the  mucosa,  and  in  the  superficia.1 
portion  of  the  sub-mucosa.  Nevertheless,  as  ^Gougenheim  has 
pointed  out,  '  this  tumefaction,  which  to  all  appearance  is  so  con- 
siderable and  so  rigid  during  life,  diminishes  notably  after  death. 
And  this  fact  has  led  to  much  miisconception  as  to  its  nature. 
The  same  author  has  usefully  drawn  attention  to  the  fact  that 
when  perichondritis  and  caries  take  place  in  the  course  of  a 
laryngeal  tuberculosis,  true  oedema  may  occur  ;  but  this  circum- 
stance is  one  of  comparative  rarity,  and  is  less  likely  to  lead  to 
suffocative  stenosis  than  in  other  forms  of  oedema. 

^Fraenkel  has  shown  that  tuberculous  infiltration  may  extend  to 
the  laryngeal  muscles.  Heinze,  however,  doubts  its  frequenc}^ 
and  only  found  the  condition  twice  in  fifty  cases.  The  laryngeal 
paralyses,  especially  of  adduction,  that  are  sometimes  seen  in 
laryngeal  tuberculosis,  may  be  due  to  this  cause,  but  are  more 
frequently  explained  by  a  simple  mechanical  impediment  to  move- 
ment of  the  crico-arytenoid  articulation  as  the  result  of  a  general 
infiltration  of  the  joint.  Neither  true  anchylosis  nor  luxation 
of  this  articulation  is  of  common  occurrence  in  laryngeal 
phthisis.  In  frequent  instances  the  paralyses  are  the  expres- 
sion of  general  weakness,  the  expiratory  volume  of  air  in  the 


TUBERCULOUS  LARYNGITIS. 


405 


lungs  being  insufBcient  to  produce  due  vibration  of  the  cords. 
In  other  cases  a  more  or  less  temporary  paresis  may  be  induced 
by  intercurrent  catarrhal  inflammation.  Unilateral  and  ab- 
ductive  laryngeal  paralysis  in  phthisis  is  more  frequent  on  the 
right  than  the  left  side,  and  may  then  be  due  to  compression  of 
the  right  recurrent  nerve  by  pleuritic  adhesions,  or  consohdation 
at  the  apex.  The  same  nerve  may  become  involved  in  en- 
larged bronchial  glands  on  either  or  both  sides.  And  lastly, 
abductive  paralysis,  either  uni-  or  bi-lateral,  may,  equally  with 
loss  of  adductive  power,  be  due  to  intrinsic  disease  of  the  dilating 
muscles. 

3.  Ulcerations  of  laryngeal  phthisis  are  characterized  by  their 
small  size,  multiple  character,  and  their  tendency  to  coalesce  and 
to  extend  laterally  rather  than  to  penetrate  deeply.  I  cannot  say 
that  I  have  seen  much  variation  in  their  shape  in  different  situa- 
tions, as  mentioned  by  Cohen,  except  that  on  the  vocal  cords  they 
have  a  less  carious,  mouse-nibbled  appearance.  As  before  men- 
tioned, erosions,  non-tuberculous  in  character,  may  appear  in  the 
larynx  of  a  tuberculous  patient,  the  subject  of  a  fortuitous  catarrh. 
Doubtless  some  of  those  that  heal  under  treatment  are  of  this 
nature. 

Concerning  the  character  of  the  Iar3mgeal  ulcer,  the  material 
for  Heinze's  observations  were  fifty  patients  from  amongst  those 
who  died  with  pulmonary  phthisis  during  the  year  1876  at  the 
Jacob  Hospital ;  and  the  only  basis  for  a  choice  of  cases  was  that 
the  throat  should  be  in  some  manner  abnormal.  Of  this  number 
forty-nine  presented  ulcerative  process  in  the  larynx,  and  one  an 
intense  catarrh,  but  no  ulceration.  Heinze  further  discovered 
that  of  these  forty-nine  cases,  the  ulceration  was  tuberculous  in 
83  per  cent.,  and  in  17  per  cent,  non-tuberculous.  It  will  thus  be 
seen,  that  according  to  this  painstaking  observer  the  great  ma- 
jority of  ulcerations  in  phthisical  patients  are  of  tuberculous 
character ;  and  moreover  he  afiirms  that  whenever  tubercle 
could  not  be  found,  the  loss  of  substance  amounted  to  merely  an 
erosion  of  the  mucous  membrane  similar  in  character  to  the 
aphthous,  or,  as  Virchow  has  called  it,  the  lenticular  ulcer,  which 
has  been  observed  not  only  alongside  of  tuberculous  ulcers,  but 
even  alone  in  phthisical  individuals  as  well  as  in  the  throat  affec- 
tions of  the  various  exanthemata. 

^*^John  Mackenzie,  in  allusion  to  these  so-called  aphthous  erosioiis  of  the  older  writers, 
describes  them  as  diphtheritic  ulcerations,  occurring  in  laryngeal  phthisis.  They  are  mort 
common  in  the  trachea,  but  'are  met  with  less  frequently  in  the  larynx  and  pharynx.  In 
the  former  they  select  the  laryngeal  aspect  of  the  epiglottis,  the  anterior  surface  of  the 
arytenoid  cartilages,  and  the  inter-arytenoid  fold  as  their  favourite  seats.  In  the  pharynx 
he  has  seen  them  most  frequently  in  the  pyriform  sinuses,  where  they  sometimes  assume  a 


4o6 


DISEASES  OF  THE  THROAT  AND  NOSE. 


considerable  size.  Their  occurrence  here  is  most  probably  explained  by  the  accumulation 
in  these  cavities  of  irritant  sputa.'  This  author  believes  that  their  anatomical  appearances, 
which  he  describes  with  his  usual  care  and  minuteness,  '  leave  no  room  for  doubt  that 
these  ulcerated  areas  are  the  result  of  a  circumscribed  superficial  diphtheritic  inflammation 
of  the  mucous  membrane  ;  that  is  to  say,  an  infiltration  of  its  tissues  with  so  rich  and 
rapid  cell-proliferation  as  to  eventuate  in  necrosis  and  sloughing  of  the  superficial 
layers.' 

While  fully  agreeing  with  the  accuracy  of  this  observation,  as 
well  as  with  the  details  of  the  description,  I  cannot  forbear  an 
expression  of  opinion  that  the  use  of  the  word  diphtheritic  in  this 
connection  is  unfortunately  misleading,  and  much  less  happy  than 
the  old  term  aphthous,  or  the  more  modern  one  of  corrosive,  or 
infective.  If  a  change  were  desirable,  the  word  membranous  would 
accurately  and  without  risk  of  confusion  describe  the  condition 
referred  to. 

There  has  been,  since  the  time  of  Louis,  considerable  specula- 
tion and  much  discussion  as  to  the  infective  power  of  the  sputa  of 
phthisical  patients  with  cavities  in  the  lungs  to  produce  laryngeal 
manifestations,  and  since  the  discovery  of  the  tubercle  bacillus 
this  view  has  obtained  renewed  favour.  It  cannot,  however,  in 
our  judgment  be  maintained,  first  because  our  daily  cHnical  ex- 
perience gives  proof  that  not  only  tuberculous  ulceration,  but  the 
tubercle  bacilli  are  to  be  found  in  both  pharynx  and  larynx,  with 
almost  negative,  or  at  least  only  incipient,  pulmonary  symptoms  : 
and  also  because  laryngeal  evidences  are  often  absent  in  cases  in 
which  there  are  extensive  cavities  in  the  lungs.  Moreover, 
tuberculous  infiltration,  which  is  one  of  the  earliest  and  an 
invariable  manifestation  of  the  disease,  may  proceed  to  even  an 
extreme  stage  without  there  being  any  breach  of  surface. 

4.  Necrosis  and  caries  may  attack  any  of  the  cartilages  of  the 
larynx,  and  are  probably  much  more  common  than  is  generally 
supposed ;  for  on  the  authority  of  Heinze,  though  extrusion  of 
portions  are  not  of  very  frequent  occurrence  during  life,  evidence 
of  this  fact  is  rarely  absent  on  autopsy.  Reference  to  the  post- 
mortem appearances  and  the  descriptions  appended  to  Figs.  104, 
105,  and  108,  Plates  XI.  and  XII.,  sufficiently  attest  the  ac- 
curacy of  this  statement. 

Beverley  Robinson,  in  the  article  already  referred  to,  denies  the  frequency  of  abscess  in 
relation  to  the  perichondria!  changes  in  laryngeal  phthisis,  with  which  view  I  entirely 
agree  ;  but  I  am  bound,  as  the  result  of  an  extended  experience  derived  from  post-mortem 
examinations,  to  differ  as  completely  from  his  view  that  *the  instances  are  rare  indeed  in 
which  the  cartilages  in  this  disease  become  either  carious  or  necrosed.'  I  believe  the  exact 
converse  to  be  the  fact,  at  least  as  we  see  the  disease  in  this  country. 

5.  New  growths  (Fig.  72,  Plate  VIII.),  in  connection  with 
tuberculous  laryngitis,  may  occur  in  all  portions  of  the  larynx, 


TUBERCULOUS  LARYNGITIS.  W 

and  are  of  the  nature  of — (i)  granular  hyperplasice,  or  gramilomata. 
According  to  ^^John  Mackenzie,  to  whom  we  are  again  indebted 
for  systematized  description  of  these  tubercular  tumours,  the 
variety  under  notice  is  '  anatomically  allied  to  granulation  tissue, 
and  may  be  regarded  as  representative  of  a  corrective  process- 
es a  natural  step  towards  cicatrization,'' 

(2)  Papillomatoid  or  wart-like  excrescences  are  of  less  frequent 
occurrence.  They  are  generally  to  be  found  on  the  posterior 
laryngeal  wall,  and  Stoerk  maintains  that  their  presence  in  the 
inter-arytenoid  fold  is  an  infallible  sign  of  incipient  tuberculosis  ; 
^^Mandl  also  attached  considerable  diagnostic  importance  to  their 
presence :  I  think,  however,  that  they  are  quite  as  often  seen  in 
connection  with  syphilis,  or  even  in  chronic  laryngitis  indepen- 
dently of  any  specific  dyscrasia.  In  each  there  is  a  distinct 
histological  character  differentiating  them  from  each  other,  and 
from  true  papillomata. 

(3)  Solitary  tumours  of  the  windpipe,  which  are  truly  tubercular 
in  character,  were  also  first  noticed  by  John  Mackenzie.  Two 
specimens  are  described,  and  are  believed  by  that  author  to  be 
unique — they  must  certainly  be  of  great  rarity. 

*  Such  tumours  doubtless  have  a  similar  origin  to  the  so-called  "metastases"  in  the 
laryngeal  mucous  membrane,  which  take  their  departure  from  old  tubercular  disease  of 
other  organs,  as  the  kidney  (^-^Kohnhorn)  and  bronchial  glands  (^^  Lennox  Browne).' 

The  post-mortem  appearances  of  a  larynx  affected  with 
laryngeal  tuberculosis  cannot  perhaps  be  better  given  than  by 
description  of  what  was  seen  in  three  typical  cases  already 
reported  by  Dundas  Grant  and  myself ;  the  appearances  in  two 
of  them  are  appended  as  coloured  illustrations  to  this  work  in 
Plates  XI.  and  XII.  It  will  be  seen  that  almost  every  condition 
to  which  I  have  referred  as  occurring  during  Hfe  is  verified  in 
one  or  other  of  the  examples. 

The  first  specimen  was  taken  from  the  body  of  a  man,  set.  36, 
who  was  admitted  into  the  Central  Throat  and  Ear  Hospital  in 
September,  1878.  He  had  suffered  with  winter  cough  and  hoarse- 
ness for  three  and  a  half  years ;  dysphagia,  and  almost  complete 
loss  of  voice,  for  two  and  a  half  years. 

Jn  life  his  larynx  presented  the  following  features  (Figs.  106  and  107,  Plate  XIL)  : 
Mucous  membrane  very  pale  ;  epiglottis  apparently  normal ;  around  both  arytenoids  there 
was  considerable  swelling,  both  more  marked  on  the  left  side  ;  the  surface  of  the  inter- 
arytenoid  fold,  the  left  ventricular  band,  and  left  vocal  cord,  were  covered  by  an  irregularly 
connected  granular  ulceration.  The  active  adductive  power  of  the  left  cord  was  greatly 
impeded  by  the  mechanical  obstruction  of  the  swollen  arytenoid  cartilage. 

The  autopsy  revealed  very  advanced  disease  in  the  lungs,  and  the  following  laryngeal 
chane;es  (Fig.  loS,  Plate  XIL)  : 


408 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  mucous  membrane  generally  was  exceedingly  pale.  Epiglottis,  normal  in  size  and 
form,  but  presenting  on  its  laryngeal  surface  several  small  follicular  elevations.  There 
was  much  irregular  thickening  of  the  ary-epiglottic  folds,  and  the  mucous  membrane  over 
them  was  loose  and  baggy.  Over  both  cornicula  and  arytenoids  the  mucous  membrane 
presented  a  tuberculated  appearance,  the  elevations  being  of  a  greyish  colour,  and  of  the 
size  of  pins'  heads.  The  right  ventricular  band  contained  in  its  posterior  two-thirds 
a  dense  material  of  almost  cartilaginous  consistency,  extending  from  above  the  vocal 
process  forward.  The  left  ventricular  band  was  almost  completely  removed,  and  covered 
by  a  weak-looking  ulcer,  with  irregular  elevated  margins,  and  a  rough  but  slightly 
elevated  granular  floor,  the  anterior  half  of  the  base  of  the  ulcer  being  densely  indurated. 
There  was  great  thickening  of  both  vocal  cords,  notably  of  the  middle  third  of  the  left  one. 

On  the  inner  aspect  of  the  right  arytenoid  cartilage  there  was  a  curious  excavation,  and 
the  vocal  process  was  ossified,  bare  and  rough.  The  joint  presented  a  slight  degree  of 
eburnation.  The  upper  portion  of  the  left  arytenoid  cartilage  down  to  the  level  of  the 
vocal  process  was  converted  into  a  rough  calcareous  nodule  about  the  size  of  a  small  pea. 
It  lay  loosely  in  the  surrounding  soft  tissues,  and  rested  on  the  lower  part  of  the  cartilage, 
which  was  rough,  gritty,  of  a  brown  colour,  and  only  held  in  position  by  the  vocal  cords, 
the  joints  being  completely  disorganized,  and  the  articular  surfaces  quite  carious. 

Examining  the  cricoid  cartilage,  there  was  found  on  the  right  side  of  its  summit, 
internal  to  the  crico-arytenoid  joint,  a  portion  so  hardened  as  to  resemble  more  than  any- 
thing the  structure  of  dentine,  with  a  cavity  in  it  of  the  size  of  a  millet-seed,  and  very 
suggestive  of  that  of  a  carious  tooth. 

T/ie  cartilages  were  all  in  a  prematurely  advanced  state  of  ossification. 

Under  the  microscope^  a  vertical  section  through  the  left  cord  and  the  ulcer  on  the  left 
ventricular  band,  showed  that  all  the  structures  were  infiltrated  by  a  quantity  of  small 
round  cells,  the  grouping  of  which  bore  unmistakable  resemblance  to  recognised  types  of 
tubercular  material,  albeit  that  giant-cells,  forming  the  centres  of  the  groups  of  leucocytes, 
could  not  be  distinctly  made  out. 

In  another  case,  a  male,  aged  29,  treated  in  April,  1880,  in 
whom  laryngeal  manifestations  were  also  developed  after  evidence 
had  been  afforded  of  pulmonary  phthisis  : 

Post-mortem  examination  showed  the  following  state  of  matters.  Of  the  epiglottis  only 
the  lowest  fifth  remained  as  a  mere  stump,  with  a  very  irregular  eroded  margin.  The 
tissues  over  the  arytenoid  cartilages  were  much  increased  in  bulk.  The  vocal  processes 
were  eroded  and  bare,  each  lying  in  the  centre  of  an  ulcer. 

A  pale,  shallow  ulcer,  with  well-defined  margin,  extended  over  the  whole  of  the  inner 
wall  of  the  larynx,  from  the  edges  of  the  ary-epiglottic  folds,  down  to  the  mucous  mem- 
brane of  the  trachea.  The  floor  of  this  ulcer  had  a  peculiar  worm-eaten  appearance,  and 
was  thickly  beset  with  small  elevations  like  grains  of  semoHna.  These,  when  picked 
away,  consisted  of  a  yellow,  crumbly,  and  gritty  tuberculosis-looking  matter,  leaving 
behind  small  apertures,  apparently  the  mouths  of  gland-ducts,  since  the  material  under 
the  microscope  was  seen  to  consist  of  epithelial  and  pus  cells  in  all  stages  of  fatty 
degeneration.  The  ventricular  bands  were  much  thickened,  almost  occluding  the  ven- 
tricles. The  vocal  cords  were  in  a  similar  condition ;  the  cartilages  were  mobile,  and 
apparently  healthy. 

Microscopical  examination  of  a  section  through  the  anterior  part  of  the  ulcer  on  the  left 
side  of  the  larynx  revealed  the  presence  of  tubercular  infiltration,  as  evidenced  by  the 
existence  of  a  fine  cell-material,  arranged  in  masses  in  which  giant-cells  could  be 
recognised. 


The  last  example  differs  from  the  preceding,  inasmuch  as 
tuberculous  ulceration  of  the  tongue  had  occurred  two  and  a  half 


TUBERCULOUS  LARYNGITIS. 


years  prior  to  either  laryngeal  or  pulmonary  manifestations.  The 
patient  was  a  male,  aged  48  years,  admitted  into  hospital  in 
January,  1879,  with  a  history  clear  of  suspicion  of  syphilis. 

On  local  examination  during  life  the  objective  signs  were  : 

(a)  Tongtie  (Fig.  I02,  Plate  XI.)  pale,  flabby,  indented,  r.nd  on  it  two  pale,  shallow 
ulcers,  with  small  grain-like  elevations  on  their  floors,  and  having  slightly  raised  irregular 
margins.  Of  these  ulcers  one  was  situated  on  the  under  surface  of  the  left  side,  near  the 
lip  ;  the  other  on  the  right  side,  about  midway  in  its  length, 

{b)  In  the  larynx,  as  seen  with  the  mirror  (Fig.  loi,  Plate  XL),  there  was  observed 
congestion  of  the  epiglottis,  with  ulceration  on  its  laryngeal  surface,  especially  toward  the 
right  side.  Over  the  right  arytenoid  cartilage  the  tissues  were  so  swollen  as  to  form  a 
large  pyriform  tumour,  occluding  the  greater  portion  of  the  right  vocal  cord.  The  left 
presented  the  same  condition  in  a  minor  degree.  The  right  ventricular  band  was  much 
swollen.    The  whole  larynx  was  bathed  in  a  mucous  fluid. 

On  post-inortejn  inspection  (two  months  after  admission),  the  advanced  tubercular 
disease  in  the  lungs,  and  the  presence  of  scrofulous  abscesses  in  the  epididymes,  etc., 
testified  to  the  nature  of  his  constitutional  disease. 

The  ulcers  on  the  tongue  (Fig.  103,  Pi-ATE  XI.)  were  changed,  in  so  far  as  their  edges 
had  become  pale  and  sodden-looking,  and  their  floors  presented  a  raw-meat  appearance, 
the  muscular  fibres  being  laid  bare,  and  all  trace  of  the  grain-like  elevations  having 
disappeared. 

In  the  larynx  (Figs.  104  and  105,  Plate  XI.)  the  mucous  membrane  generally  was  pale. 
The  epiglottis  was  much  thickened,  and  on  its  free  border,  from  a  short  distance  to  the 
left  of  the  middle  line  down  to  the  right  ary-epiglottic  fold,  was  an  excavated  ulcer,  with 
rough  irregular  edges,  and  a  pale,  granular  base.  This  ulcer  extended  over  the  greater 
portion  of  the  right  half  of  the  laryngeal  surface  of  the  epiglottis,  and  dovy-n  to  the  right 
ventricular  band.  There  were  also  two  other  smaller  ulcers  of  less  depth,  and  somewhat 
oval  in  shape,  on  the  left  half  and  middle  of  the  epiglottis  respectively.  The  right  ary- 
epiglottic  fold  was  swollen  out  into  a  flabby,  wrinkled,  somewhat  globular  tumour.  The 
left  formed  a  less  prominent  swelling.  Of  the  ventricular  bands,  the  right  was  represented 
by  a  firm  longitudinal  swelling,  concealing  the  ventricle.  It  was  irregular  in  outline,  of  a 
soft  semi-cartilaginous  consistency,  and  quite  movable  on  the  subjacent  cartilages.  The 
[eft  was  normal.  The  right  vocal  cord  bore  on  its  posterior  part,  corresponding  to  the 
mner  surface  of  the  arytenoid  cartilage,  an  ulcer  extending  into  the  adjacent  part  of  the 
ventricle,  and  containing  on  its  floor  a  portion  of  the  arytenoid  cartilage,  which  had 
become  bare  and  rough.    The  left  vocal  cord  was  comparatively  healthy. 

The  microscopical  appearance  in  this  case  was  that  of  tubercular  infiltration  of  all  the 
tissues  mvolved. 

Symptoms  :  A.  Functional. — Voice. — Failure  of  the  voice  is 
a  very  early  and  frequent  symptom.  As  already  remarked, 
this  may  be  due  eiiner  to  local  lesion  or  to  insufficient  motor 
power  of  diseased  lungs.  It  may  be  quite  early  aphonic  ;  more 
commonly,  however,  it  is  affected  just  in  proportion  to  the 
amount  of  the  local  lesion  ;  and  the  ordinary  vocal  symptoms  of 
congestion,  thickening  or  ulceration,  already  described  at  length 
when  considering  other  forms  of  laryngitis,  are  witnessed. 

The  following  is  an  instance  of  loss  of  voice  as  an  early 
symptom  of  phthisis  depending  on  (tuberculous)  changes  within 
the  larynx  : 


DISEASES  OF  THE  THROAT  AND  NOSE. 


G.  T.  M.,  aged  21,  residing  at  Cardiff,  and  in  training  for  a  schoolmaster,  came  under 
my  care  on  August  30,  1886,  on  account  of  loss  of  voice,  without  any  other  symptom  of 
cough,  night-sweats,  or  emaciation.  The  patient  spoke  with  distinct  hoarseness,  which 
was  worse  after  reading  and  towards  the  end  of  the  day.  With  the  laryngoscope 
(Fig.  CXL.)  it  was  seen  that  there  was  congestion,  with 
weakness  of  adduction  of  both  vocal  cords,  and  that  the 
right  one  was  thickened  and  somewhat  ulcerated.  Atiscul- 
tation  demonstrated  a  small  area  of  dulness  at  the  left  base, 
with  vocal  fremitus,  absence  of  breath-sounds,  and  occasional 
rhonchus  on  forcible  inspiration. 

On  questioning  him,  it  was  elicited  that  he  had  had  several 
severe  'colds'  on  the  chest,  with  pneumonia  of  the  left  side, 
two  years  ago.    A  very  unfavourable  prognosis  was  given, 
and  on  recent  inquiry  (March,  1887)  I  learn  that  the  patient, 
as  anticipated,  has  been  obliged  to  abandon  his  vocation,  and  that  in  the  past  severe 
winter  his  voice  and  general  health  have  both  continued  to  deteriorate. 

There  is  a  peculiarit}^  in  the  voice  of  consumptives  with 
laryngeal  mischief  not  generally  noticed  :  this  is  found  in  the 
rapidity  with  which  the  voice  changes  in  character  during  a  quite 
short  conversation,  from  a  gruff  hoarseness  to  a  high  falsetto, 
which  as  quickly  passes  into  a  toneless  whisper.  These  changes 
are  probably  influenced  by  lodgment  and  dislodgment  of  secretion, 
and  also  by  peripheral  nerve-irritation  affecting  the  tension  of 
the  cords.  A  somewhat  similar  though,  to  the  practised  ear, 
distinct  condition  is  occasionally  noticed  in  patients  with 
laryngeal  growths,  variation  in  the  situation  of  which  produces 
quick  alterations  in  voice.  In  both  diseases  there  sometimes 
occurs  a  true  diphthonia  or  double  voice — the  cause  being  in 
the  one  under  consideration  the  lodgment  of  mucus  between  the 
vocal  cords  during  speech,  and  is  not  peculiar  to  phthisis,  or  it 
may  be  accounted  for  by  a  paresis.  In  the  case  of  a  growth  in 
the  larynx,  it  is  the  neoplasm  itself  which  causes  this  peculiarity. 

Respiration,  although  short  and  somewhat  frequent,  is  not,  as 
a  rule,  embarrassed  in  the  early  stage,  but  as  tumefaction  leads 
to  mechanical  loss  of  mobility,  and  the  vocal  cords  themselves 
become  thickened  and  ulcerated,  extreme  dyspncea,  with  stridor 
and  paroxysmal  aggravations,  may  ensue.  Stenotic  suffocation  is 
less  marked  in  laryngeal  phthisis  than  in  other  similar  conditions, 
as  of  syphiHs  or  cancer,  whether  it  be  due  to  the  semi-soHd  in- 
filtration of  tubercle,  or  to  the  more  rarely  witnessed  true  oedema 
which  may  result  from  perichondrial  and  chondrial  changes. 

Cough  is  naturally  a  prominent  and,  on  many  accounts,  a  very 
distressing  symptom  in  the  advanced  stages,  whether  it  be  caused 
by  local  or  pulmonary  lesions,  since  the  mechanical  irritation  in 
the  larynx  produces  most  acute  pain,  and  the  cough  paroxysms 
are  followed  by  extreme  prostration.    At  a  very  early  period 


TUBERCULOUS  LARYNGITIS.  4ir 

the  feeling  of  a  desire  to  clear  the  throat  of  a  foreign  body 
predisposes  to  a  worrying,  unproductive  cough.  Expectoration 
is  not  copious,  nor  more  than  glairy  in  character,  until  suppura- 
tion is  established.  Haemorrhages  from  the  larynx,  common 
enough  in  cancer  and  syphilis,  are  but  rare  in  phthisis,  even 
when  there  is  advanced  necrosis,  and  it  is  very  difficult,  even 
when  suspected,  to  decide  that  the  bleeding  has  originated  in  that 
region.  Occasionally,  however,  the  spot  at  which  the  vessel  has 
given  way  can  be  seen. 

In  one  instance  [vide  Fig.  69,  Plate  VIII.),  a  recent  clot  was  observed  on  the  vocal 
cord  after  a  very  moderate  haemoptysis,  in  which  there  was  but  slight  corroborative  local 
evidence  of  laryngeal  tuberculosis,  nor  would  the  result  of  stethoscopic  examination  have 
been  sufficient  to  justify  the  grave  prognosis  suggested  by  the  laryngeal  appearance,  and, 
unfortunately,  verified  by  the  subsequent  history  of  the  case. 

Deglutition. — Difficulty  of  swallowing  is  by  no  means  an 
invariable  accompaniment  of  laryngeal  phthisis,  but  when  present 
it  is,  without  doubt,  the  symptom  which  most  tends  to  hurry  on 
the  fatal  termination,  and  is  the  one  on  which  account  patients 
most  frequently  seek  relief  of  the  throat  specialist.  The  trouble, 
at  least  in  early  stages,  is  mainly  mechanical,  from  impediment 
to  the  mobility  of  the  epiglottis,  which  causes  fluids  to  pass 
downwards  into  the  larynx,  and  backwards  into  the  naso- 
pharynx. Dysphagia  is  flrst  experienced  only  in  taking  fluids, 
but  as  soon  as  there  is  ulceration,  and  when  there  is  extreme 
swelHng  of  the  arytenoid  cartilages,  or  disease  of  the  cricoid, 
attempts  at  the  deglutition  of  solids,  unless  first  artificially 
masticated  and  made  bland,  cause  the  act  to  be  acutely  painful. 
As  a  rule,  semi-solid  food  and  of  tepid  consistence  is  that  most 
easily  taken. 

This  symptom  of  Pain  during  the  exercise  of  function  is  of 
great  diagnostic  value  when  there  is  the  least  idea  that  the 
disease  may  be  syphilitic.  When,  however,  the  parts  can  be 
kept  at  rest  from  cough,  or  when  the  patient  is  not  eating,  it  is 
surprising  how  little  local  pain  is  felt ;  here,  again,  differentiating 
this  disease  from  carcinoma.  In  the  early  stages,  moreover,  there 
may  be  but  little  pain,  and  nothing  more  than  a  sense  of  discom- 
fort or  of  a  foreign  body.  In  exceptionally  happy  cases,  consider- 
able disintegration  of  the  tissues  will  go  on  without  any  further 
disorder  of  sensation.  In  some  instances  there  is  tenderness  to 
external  touch  of  the  larynx  at  quite  the  commencement  of  the 
disease.  Where  there  is  perichondritis  the  skin  and  soft  tissues 
covering  this  region  are  often  swollen  and  inflamed,  and  are  then 
intensely  sensitive  to  any  external  manipulations. 


412 


DISEASES  OF  THE  THROAT  AND  NOSE. 


B.  Physical. — Most  of  the  physical  changes  have  been  already 
alluded  to  in  our  remarks  on  the  pathology.  It  remains  to  more 
minutely  describe  the  typical  lar3^ngoscopic  features. 

Colour. — (Figs. 68,  74,  etc., Plate  VIII.,  and  Figs.  106,  and  107, 
Plate  XII.)  The  first  evidence  in  the  mirror  of  laryngeal  tuber- 
culosis is  a  paleness  of  the  mucous  membrane  ;  and  it  is  something 
more  than  an  anaemia,  for  while  all  parts  of  the  larynx,  naturally 
pink,  will  assume  a  muddy  and  greyish  hue,  the  vocal  cords  will 
often  be  found  congested,  and  many  engorged  capillary  vessels  will 
be  seen  ramifying  on  that  portion  of  the  mucous  membrane  con- 
sidered anaemic.  As  the  stage  of  tumefaction  arrives,  the  colour, 
while  it  does  not  become  less  pale,  is  decidedly  more  opaque, 
except  on  the  epiglottis,  which,  as  it  becomes  thickened,  may  lose 
its  natural  buff  hue,  and  assume  a  pale  rosy  tint  (Figs.  71,  73, 
and  75,  Plate  VIII.,  and  Fig.  104,  Plate  XII.).  The  mucous 
membrane  of  the  larynx,  and  especially  the  epiglottis,  is  excep- 
tionally heightened  in  colour  in  the  case  of  acute  tuberculosis,  or 
as  a  result  of  an  intercurrent  catarrh. 

Ulceration,  except  on  the  epiglottis  and  vocal  cords,  is  not 
preceded  by  hyperaemia,  but  when  the  ulcers  are  formed  there  is 
often  a  faint  red  line  at  their  circumference  (Figs.  72,  73,  and  75, 
Plate  VIII.).  The  surface  of  the  vocal  cords,  where  loss  of 
tissue  has  taken  place,  is  frequently  of  a  greyish-white  or  pale 
yellow  colour,  while  the  rest  of  the  cord  is  congested  (Figs.  70,  75, 
etc.).  The  ulceration  of  the  vocal  cord  is  seldom  deep ;  but  it 
may  extend  to  the  arytenoid  cartilage,  and  lead  to  caries  and  even 
extrusion. 

Form  and  Texture. — Thickening  caused  by  infiltration  of  the 
submucous  tissue  characterizes  the  second  stage  of  laryngeal 
phthisis.  The  part  first  affected  may  be  one  or  both  vocal  cords, 
which  may  be  thickened  along  their  whole  length  or  irregularly ; 

but  much  more  commonly  the  first  symptom  is 
evidence  of  deposit  in  the  inter-arytenoid  space. 

This  sketch  (Fig.  CXLL)  indicates  the  general  thickening  in 
the  inter-arytenoid  space,  and  also  of  the  ventricular  bands.  It 
f      was  taken  from  a  male  patient,  aged  29,  under  the  care  of  my 
deceased  colleague,  Llewelyn  Thomas.    There  was  evidence  of 
commencing  disease  in  each  apex,  especially  the  right. 

Then  the  well-known  and  often-described 
swelling  of  the  arytenoid  cartilages  is  seen,  giving 
rise  to  the  appearance  of  two  pear-shaped  bodies,  the  larger  ends 
of  which  meet  in  the  centre  line,  and  consist  of  the  swollen  and 
no  longer  distinguishable  cartilages  of  Wrisberg  and  of  Santorini, 


Fig.  CXLL 


TUBERCULOUS  LARYNGITIS. 


4r3 


tapering  off  more  or  less  in  proportion  to  the  swelling  of  the  ary- 
epiglottic  folds  until  they  join  the  epiglottis  (Figs.  71  and  74, 
Plate  VIII.,  and  Figs.  T06  and  107,  Plate  XII,). 

Equally  unrecognisable  is  the  condition  of  the  last-named  part, 
which  becomes  so  misshapen  that  no  longer  is  its  free  edge, 
superior  or  inferior  surface,  or  any  ligamentous  fold,  to  be  dis- 
tinguished, the  whole  being  swollen  into  a  horse-shoe  or  turban- 
hke  shape,  which  lies  nearly  horizontally  at  the  base  of  the 
tongue,  or  is  so  flexed  on  itself  as  to  resemble  a  lateral  view  of  the 
index-finger  in  a  similar  position  (Fig.  74,  Plate  VIII.,  and  also 
Fig.  CXI.,  p.  202). 

Some  allusion  has  been  made  to  the  character  of  the  ulcera- 
tions :  their  peculiarity  is  their  worm-eaten,  carious  appearance, 
showing  that  degeneration  has  not  commenced  at  the  surface, 
but  in  the  deeper  tissues,  or  rather,  as  is  probably  the  case,  that  the 
secretion  of  the  acinous  glands  has  first  undergone  degeneration  ; 
the  glands  have  swollen  and  have  given  way  at  the  point  most 
favourable  for  exit  of  the  retained  matter,  namely,  at  the  surface. 
These  small  ulcers  then  unite  by  breaking  down  the  inter-acinous 
tissue,  and  so  form  large  necrosing  areas  (Figs.  73  and  75, 
Plate  VIII.).  Narrowing  of  the  glottis  is  often  the  result  of 
tissue-changes,  but  there  is  rarely  any  attempt  at  cicatrization. 
Paralysis  of  one  or  both  vocal  cords  is  frequently  seen,  and  may 
be  due  either  to  mechanical  impediment  or  to  nerve-pressure 
(Fig.  75,  Plate  VIII.). 

Mandl  was  one  of  the  first  to  draw  attention  to  the  fact, 
illustrated  in  the  figure  referred  to,  that,  contrary  to  experience 
in  other  paralyses  of  the  recurrent  laryngeal  nerve,  the  right  nerve 
is  much  more  frequently  pressed  upon  than  the  left  in  cases  of 
laryngeal  phthisis.  This,  as  already  noted,  is  explained  by  the 
anatomical  relation  of  the  right  nerve  to  the  apex  of  the  lung. 

Secretion. — As  mentioned  when  treating  of  the  sputa  under 
the  symptom  of  Cough,  the  secretion  is  altered  in  character  from  a 
glairy,  viscid  exudation  of  moderate  amount 
to  a  copious  muco-purulent  discharge. 

The  accompanying  sketch  (Fig.  CXLII.)  not  only 
illustrates  the  character  of  tuberculous  ulceration,  but 
the  manner  in  which  the  mucus,  when  tenacious,  forms 
bridges  between  the  vocal  cords.  This  condition  is  not 
peculiar  to  laryngeal  phthisis,  and  is  to  be  witnessed 
especially  in  that  form  of  inflammation  known  as  laryn- 
gilis  sicca  (p.  278). 

Fig.  CXLIL 

V^henever  there  is  actual  chondrial 
caries,  the  odour  is  very  characteristic,  though  foetor  of  the  dis- 
charge may  be  also  due  to  pulmonary  causes. 


414  DISEASES  OF  THE  THROAT  AND  NOSE. 


If  doubt  exists  as  to  the  diagnosis,  the  secretion  may  be 
examined  by  the  method  proposed  by  Dr.  Fenwick,  of  boiHng 
with  a  solution  of  potash,  to  destroy  the  mucous  elements,  and 
submitting  the  deposit  to  microscopic  investigation.  In  such  a 
case  elastic  lung-tissue  will  often  be  seen  at  a  period  prior  to  the 
existence  of  well-marked  auscultatory  signs.  This  method  of 
examination  has,  however,  been  almost  entirely  superseded  in 
favour  of  the  more  certain  results  to  be  obtained  by  investigation 
for  the  tubercle  bacillus. 

C.  Miscellaneous. — There  can  be  no  reason  for  entering 
largely  into  general  symptoms,  except  to  remark  that  increased 
frequency  of  the  pulse  and  range  of  body-temperature,  as  well  as 
evidence  of  mal-assimilation,  giving  rise  to  dyspepsia  and  loss  of 
weight,  are  of  as  great  importance  in  the  early  stages  of  laryngeal 
as  of  pulmonary  or  other  form  of  phthisis.  With  reference  to 
the  state  of  the  lungs,  early  and  frequently-repeated  auscultations 
should  be  made.  At  first  there  may  be  nothing  more  than  slightly 
diminished  resonance,  hardly  perceptible  increase  of  vocal  fremitus, 
and  prolongation  of  expiratory  murmur  ;  but  gradually  and  surely 
the  chest-evidences  will  become  more  strongly  marked.  It  must 
be  remembered  that  though  tubercular  disease  may  be  first 
detected  in  the  larynx,  until  recently  no  case  has  been  reported  in 
which  a  patient  has  died  of  that  disease  without  well-marked 
symptoms  in  life,  and  appearance  after  death,  of  pulmonic  disin- 
tegration. In  many  cases  of  deeply  situated  pulmonary  disease 
the  negative  evidences  afforded  by  the  stethoscope  are  apt  to 
colour  too  favourably  one's  opinion  of  laryngeal  symptoms. 

Diagnosis. — In  the  assumption  that  there  is  a  difficulty  in  differ- 
entiating tuberculosis  in  the  larynx  from  syphilis,  some  writers 
have  seriously,  and,  as  we  consider,  needlessly  exercised  their 
minds  on  the  subject.  Having  nothing  to  add  to  the  opinion 
given  by  Dundas  Grant  and  myself  in  the  article  so  often  pre- 
viously quoted,  our  remarks  under  this  heading  are  repeated  here 
with  but  slight  modification,  and  with  the  less  hesitation  because 
i^Bosworth,  Beverley  Robinson,  and  other  careful  observers 
have  since  that  time  specially  drawn  attention  to  them  as  accurately 
expressing  the  opinion  of  the  majority  of  laryngologists  : 

*  The  symptoms  as  narrated  in  the  foregoing  descriptions  are  so 
typical,  as  to  enable  even  those  unaccustomed  to  the  use  of  the 
laryngoscope  to  diagnose  the  condition  with  tolerable  certainty. 
Briefly,  the  emaciation  and  loss  of  weight,  night-sweats,  aphonia, 
cough  with  profuse  laryngorrhoea  of  semi-purulent  character,  pain 
only  in  deglutition,  more  marked  in  the  case  of  fluids,  with  ten- 


TUBERCULOUS  LARYNGITIS, 


415 


derness  on  pressure  of  the  larynx,  afford  an  unmistakable  picture 
of  the  disease  in  question. 

'  In  cancer,  besides  its  more  m.arked  cachexia,  the  disease  is 
distinguished  by  the  constant  presence  of  pain,  independently  of 
functional  acts,  as  well  as  its  occurrence  in  deglutition,  being 
more  intense  in  the  case  of  solids  than  of  fluids. 

*  The  distinctions  from  syphilis  have  been  succinctly  and  accu- 
rately considered  by  Moure.  Syphilis  gives  a  hoarse,  rather  than 
an  aphonic  character  to  the  voice ;  is,  on  the  w^hole,  free  from 
pain,  and  has  other  symptoms  of  its  own  sufficiently  distinctive  to 
afford  a  reliable  guide. 

*  Anchylosis  of  the  crico-arytenoid  articulation,  paralysis  of  laryn- 
geal muscles,  as  from  pressure  on  the  nerves  supplying  them,  or 
following  diphtheria  and  other  diseases,  are  unaccompanied  by 
general  emaciation,  unless  in  the  case  of  nerve-pressure  the 
paralysis  be  due  to  a  malignant  growth.  Thus,  in  a  general  way, 
the  symptoms,  apart  from  the  physical  signs,  give  a  fair  clue  to 
the  presence  of  laryngeal  phthisis. 

*  It  is,  however,  only  by  a  recognition  of  the  characteristic 
appearances  as  reflected  in  the  laryngoscope  that  a  certain  diag- 
nosis can  be  made.  These  appearances  are  the  pecuhar  semi- 
solid swelling  and  worm-eaten  ulceration  of  the  epiglottis  and 
ary-epiglottic  folds  often  described  by  other  authors  and  well 
illustrated  in  the  figures  accompanying  this  work.  The  swelling 
is  often  much  greater  on  one  side  than  the  other,  but  we  never 
see  tumefaction  of  the  tissues  covering  one  arytenoid  cartilage 
much  advanced  without  a  similar  condition  existing  to  some 
extent  over  the  other  side  also,  thus  distinguishing  it  from  cancer 
and  from  non-tuberculous  perichondritis.  We  have  used  the  word 
semi-solid  as  applied  to  the  swelling,  but  its  resemblance  under 
the  light  of  the  laryngoscopic  lamp  to  serous  or  purulent  effusions 
is  often  so  complete  as  to  mislead  even  practised  observers. 

*  The  ulceration  of  laryngeal  phthisis  has  been,  for  what  reason 
we  know  not,  a  stumbling-block  to  many  laryngoscopists.  Von 
^^Ziemssen  states:  "Neither  the  catarrh  nor  the  ulceration  of 
phthisical  subjects  presents  any  characteristic  signs  by  which  it 
could  be  recognised  as  such."  This  assertion  one  of  us  ventured 
to  combat  on  its  first  appearance.  We,  however,  find  Dr.  Vivian 
Poore  telling  his  students  at  the  London  University  College  that 
*'this  is  perfectly  true,  and  that  his  experience  enables  him  to 
endorse  this  assertion."  Cohen  is  of  much  the  same  opinion,  and 
says  "  that  the  aspect  of  these  ulcerations  is  hardly  sufficiently 
characteristic  for  differential  diagnosis,  without  reference  to  ths 


416 


DISEASES  OF  THE  THROAT  AND  NOSE. 


cachexia."  Even  Morell-Mackenzie,  whose  earHer  writings  taught 
differently  (see  his  essays  in  Reynolds  and  ^^Aitken),  although 
he  describes  very  minutely  and  accurately  the  characteristic  differ- 
ences between  the  various  specific  ulcerations  to  which  the  larynx 
is  subject,  now  gives  in  his  adhesion  to  Heinze,  and  is  of  opinion 
that  the  latter  "  very  properly  declines  to  accept  descriptions  of 
the  laryngoscopic  appearances  of  tubercle  (by  Ter  Maten,  Tiirck 
and  others),  remarking  that  even  in  the  case  of  a  larynx  fresh 
from  the  body,  it  is  impossible  to  determine  absolutely  with  the 
naked  eye  whether  the  ulceration  is  tubercular  or  not." 

'  Granted,  with  Mackenzie  and  Cohen,  that  in  cases  in  which 
syphilis  attacks  phthisical  patients,  by  no  means  so  common  now 
as  before  the  recognition  of  pharyngeal  tuberculosis,  the  diagnosis 
may  occasionally  be  difficult,  we  cannot,  in  spite  of  the  array  of 
authorities  which  we  have  quoted  against  ourselves,  admit  the 
non-existence  of  a  truly  characteristic  tuberculous  ulceration  in 
the  larynx.  On  the  contrary,  we  believe  in  it  most  firmly,  and  we 
venture  to  speak  boldly  on  this  question  from  a  clinical  stand- 
point, in  opposition  to  the  timorous  who  will  not  admit  tubercle 
without  distinct  pulmonary  evidence  during  hfe  or  microscopic 
examination  after  death.  We  can  only  further  say  that  with  the 
exception  of  laryngeal  growths,  we  know  no  disease  in  which, 
with  the  laryngoscope,  we  can  be  so  sure  of  our  diagnosis,  and 
that,  so  far  from  being  dependent  for  confirmation  on  an  examin- 
ation of  the  chest,  we  have  in  not  a  few  instances  diagnosed  the 
disease  in  the  larynx  in  spite  of  opinions  of  eminent  auscultators 
that  the  chest  was  sound.  To  more  particularly  formularize  our 
views  on  this  important  point,  we  hold  that,  given  the  character- 
istic grey  semi-solid  infiltration  of  epiglottis,  ary-epiglottic  folds, 
or  both — -an  appearance  we  consider  almost  invariably  the  pre- 
cursor of  ulceration — there  is  a  form  of  ulcer  superimposed  on  the 
swollen  tissue,  which  we  believe  to  be  distinctly  characteristic,  and 
which  we  are  able  to  foretell  is  incurable.  In  the  absence,  how- 
ever, of  the  thickening,  the  character  of  the  ulceration  is  hardly 
less  typical.  It  is  in  itself  essentially  one  of  that  class  in  which 
there  is  absence  of  healing,  owing  to  defect  of  action.  We  do  not 
desire  to  reiterate  descriptions  often  already  detailed,  nor  can  we 
hope  to  rival  or  to  add  much,  many  as  are  the  years  that  have 
passed  since  it  was  written,  to  the  graphic  truth  of  the  word- 
picture  drawn  of  tuberculous  ulceration  by  Tiirck,  but  these  one 
or  two  points  we  would  emphasize.  The  floor  of  a  tiihercidous 
ulcer  is  pale  and  granular  and  slightly  depressed,  the  margins  are 
fairly  w^ell  marked  but  not  deeply  excavated,  the  surrounding 


TUBERCULOUS  LARYNGITIS. 


417 


parts  pale  and  languid,  and  there  is  an  appearance  of  a  spreading 
process  of  erosion  very  comparable  to  that  of  the  nibbling  of  a 
small  rodent  animal.  This  is  due  to  the  confluence  of  small 
ulcers  produced  by  the  slow  incurable  inflammation  of  the  mucous 
and  closed  follicles  of  the  mucous  membrane,  and  also  to  the 
ejection  of  minute  tubercles  which  have  worked  their  way  to  the 
surface.  Very  different  from  this  is  the  punched-out,  areolated 
excavation  which  is  seen  in  tertiary  syphilis,  and  which  may  be 
considered  suggestive  of  a  bite  rather  than  of  the  continued  nib- 
bling to  which  we  have  likened  the  tuberculous  ulcer.  Nor  need 
we  insist  on  the  angry,  hypersemic,  thickened  walls  of  a  cancerous 
ulceration,  with  its  accompanying  deformities  and  other  signs,  to 
still  further  point  the  laryngoscopic  diagnosis. 

'  We  only  ask  the  merest  tyro  in  laryngoscopy  to  study  carefully 
the  wood-cuts  of  Tiirck,  or  even  of  Cohen  and  of  Mackenzie,  to 
say  nothing  of  our  own  illustrations — which  are,  moreover,  typical, 
not  exceptional — and  having  studied  them,  to  decide  for  himself 
whether  Ziemssen  is  justified  in  stating  that  ''the  attempts  made 
to  establish  pathognomonic  peculiarities  cannot  be  said  to  have 
succeeded." 

'  So  far  have  we  indicated  with  detail  the  intrinsic  characters 
of  the  ulcer  per  se,  which  point  to  a  phthisical  condition.  As 
for  simple  chronic  laryngitis  with  ulceration,  the  rarity  of  this 
affection  is  so  great,  apart  from  phthisis,  that  Heinze  reports 
(setting  aside  cases  of  syphilis,  cancer  or  diphtheria)  but  6  per  cent, 
of  cases  of  laryngeal  ulceration  unaccompanied  by  tubercle,  and 
these  few  are  further  referred  to  typhoid.  The  further  examin- 
ation of  neighbouring  parts  enables  us  to  make  as  safe  a  pro- 
visional diagnosis  as  surgery  in  general  admits,  and  certainly 
much  more  so  than  is  usually  possible  in  the  domain  of  internal 
medicine.  Thus,  the  condition  of  the  pharynx  and  palate,  be  it 
in  the  pallid- veined  condition  of  some  cases,  or  in  the  v/ell-marked 
state  of  tubercular  ulceration  of  others,  gives  an  unmistakable 
clue  to  the  nature  of  the  malady.  The  absence  of  evidence  of 
syphilitic  disease  in  the  pharynx  and  of  the  deposit  of  cancerous 
material  in  the  neighbouring  lymphatic  glands,  further  aids  by  a 
process  of  exclusion  to  a  complete  diagnosis. 

'  The  temperature  and  the  condition  of  the  other  organs  of  the 
body  afford  collateral  evidence  to  the  importance  of  which  we 
need  only  allude,  but  with  regard  to  the  temperature,  we  have 
not  always  found,  except  in  quite  early  stages,  the  variations  of 
such  extent  as  is  usual  in  ordinary  cases  of  pulmonary  phthisis. 
This  is  due,  no  doubt,  to  the  inanition  caused  by  the  odynphagia 

27 


DISEASES  OF  THE  THROAT  AND  NOSE. 


which,  in  its  turn,  contributes  so  much  to  the  more  rapidly  fatal 
termination  of  these  cases.' 

Course,  Prognosis,  and  Termination. — As  stated  on  page 
219,  in  connection  with  tuberculosis  of  the  pharynx  and  fauces,  the 
prognosis  '  is  seldom  doubtful,'  and  we  are  not  justified  in  giving 
other  than  an  unfavourable  prognosis  either  as  to  recovery  of 
health  or  duration  of  life.  Nevertheless,  in  one  case  at  least — 
that  of  a  youth  about  seventeen — I  have  seen  entire  arrest  of 
undoubted  disease  in  both  larynx  and  lungs,  with  restoration  to 
health,  this  happy  event  being  brought  about  by  sea  voyages  to 
Australia.  In  other  cases  the  progress  of  the  disease  is  some- 
times very  slow,  and  may  become  chronic.  This  condition  arises 
when  the  infiltration  and  ulceration  are  confined  to  intra-laryngeal 
tissues,  as  the  ventricular  bands,  vocal  cords  and  laryngeal  aspect 
of  arytenoid  cartilages.  In  such  circumstances  there  is  often  but 
little  body-wasting,  and  the  principal  discomfort  may  be  that  of 
vocal  impairment.  Doubtless  in  these  cases  the  laryngitis  is 
not  always  truly  tubercular,  but  is  of  the  nature  of  a  recurrent 
catarrhal  inflammation  occurring  in  the  subject  of  pulmonary  or 
other  form  of  phthisis.  Where  the  infiltration  is  considerable, 
especially  of  the  ary-epiglottic  folds,  there  is  superadded  distress 
due  to  dyspnoea  and  laryngeal  cough.  On  the  other  hand,  when- 
ever the  epiglottis  or  the  pharyngeal  aspect  of  the  larynx  is 
involved,  and  when  perichondria!  changes  present  themselves, 
the  course  of  the  disease  rapidly  progresses  to  a  fatal  issue,  and 
gravely  influences  the  prognosis  which  the  pulmonic  symptoms 
might  otherwise  indicate.  The  cause  of  such  a  rapidly  fatal 
termination  may  be  explained  by  the  circumstance  that  the 
odynphagia,  by  preventing  the  taking  of  sufficient  nutriment, 
adds  the  effects  of  starvation  to  that  of  uncomplicated  phthisis  ; 
for  although  cases  are  not  uncommonly  reported  of  patients 
affected  with  dysphagia  from  other  causes  preserving  life  for 
nearly  the  natural  span  on  spoon-diet,  in  such  as  we  are  now 
considering  the  enfeebled  system,  unable  to  sustain  itself  on  a 
comparatively  full  diet,  is  much  less  capable  of  counteracting  by 
slops  and  sops  the  rapid  wasting  the  disease  produces.  What- 
ever the  nature  and  amount  of  the  laryngeal  evidences  of 
tubercle,  it  repeatedly  occurs  that  the  speciahst  is  not  only  able 
to  give  an  earlier  and  more  accurate  diagnosis,  but  he  may  also 
be  forced  to  give  a  far  more  grave  forecast  than  would  be  afforded 
by  auscultatory  and  general  symptoms  alone. 

Prognosis  as  to  duration  of  life  is,  that  given  the  degree  of 
pulmonary  disease,  the  rapidity  of  termination  is  greater  in 
proportion  to  the  amount  of  difficulty  in  swallowing. 


TUBERCULOUS  LARYNGITIS. 


419 


The  mode  of  death  from  local  causes  in  laryngeal  phthisis  may 
be  :  (i)  by  suffocation ;  (2)  by  inanition  and  general  marasmus ; 
and  (3)  by  haemorrhage.  The  first  may  be  possibly  relieved  tem- 
porarily by  tracheotomy,  the  second  by  artificial  feeding  per 
rectum  or  by  an  oesophageal  tube.  The  last  is  a  rare  event  as 
occurring  from  a  point  within  the  larynx. 

Treatment. — It  is  not  necessary  to  repeat  here  the  many 
details  of  general  and  local  therapeutics,  dietetics  or  hygiene 
which  have  been  so  fully  discussed  in  our  previous  chapter  on 
pharyngeal  tuberculosis,  at  page  203. 

The  indications  for  general  treatment  in  regard  to  the  local 
trouble  are  to  diminish  the  cough,  so  as  to  give  as  complete 
functional  rest  as  possible,  and  also  to  endeavour  by  internal 
remedies  to  relieve  the  irritability  of  the  upper  portion  of  the 
gullet.  For  this  latter  purpose  bismuth  and  bromide  of  potassium, 
taken  shortly  before  food,  will  often  be  found  of  great  service. 

The  hypophosphites  of  soda  and  lime  in  doses  of  five  grains  of 
each  salt  have  certainly  acted  well  in  my  practice,  in  those  cases 
in  which  the  evidence  of  the  disease  was  primarily  in  the  larynx, 
by  checking  night  perspirations,  diminishing  cough,  aiding  diges- 
tion, and  arresting  loss  of  tissue. 

I  have  no  personal  experience  of  the  most  recent  treatment  of 
phthisis — that  of  rectal  enemata  of  sulphuretted  hydrogen,  either 
alone  or  combined  with  carbonic  acid.  Another  new  treatment, 
which  is  more  properly  local,  and  is  also  founded  on  belief  in  the 
parasitic  nature  of  phthisis,  is  that  of  administration  of  germicides 
by  atomized  inhalations.  Of  these  may  be  named  those  of 
atomized  aniline,  as  recommended  by  ^^Kremianski,  of  Moscow; 
and  of  corrosive  sublimate  of  the  strength  of  i  in  5,000,  lately 
mentioned  by  2"  Reynolds.  Regarding  this  last  remedy,  it  should 
be  remembered  that  germs  are  not  the  only  things  capable  of 
destruction,  and  that  they  are  killed  with  more  difficulty  than 
are  normal  cells,  especially  in  persons  of  tuberculous  tendencies. 

Local. — In  respect  to  local  treatment,  it  is  gratifying  to  know 
that  many  authorities  eminent  in  the  general  treatment  of 
phthisis — Dr.  C.  J.  B.  Williams,  for  example — have  spoken 
in  high  terms  of  the  relief  that  may  be  given  by  local  measures 
when  the  disease  attacks  the  larynx ;  and  yet  many  general 
physicians  do  not  quite  fully  acknowledge  how  much  success 
depends  on  careful  attention  to  detail. 

A  proper  inhaler,  generating  steam  at  a  temperature  accurately 
registered  according  to  the  special  circumstances  of  the  patient 
and  the  time  of  the  year,  so  that  while  moist,  warm  air  is  inhaled. 


420 


DISEASES  OF  THE  THROAT  AND  NOSE. 


and  the  volatile  ingredient  thrown  off,  the  respiratory  muscles 
are  not  fatigued  nor  the  circulation  quickened,  is  surety  better 
than  a  jug  of  hot  water  with  a  napkin  lying  over  the  patient's 
face  and  covering  the  jug  as  advised  by  the  eminent  author  just 
named  ;  and  it  is  not  surprising  if  in  the  latter  instance  there 
is  a  strong  liability  to  induce  perspiration.  Again,  when  local 
remedies  are  applied  they  are  often  worse  than  useless,  unless  the 
mirror  guide  the  hand,  and  the  application  be  made  to  the  part 
affected,  and  to  that  only. 

Of  inhalations — in  the  anaemic  stage,  and  when  the  thickening 
is  only  commencing,  stimulating  volatile  mgredients,  as  creasote, 
the  oil  of  pine,  and  some  essential  oils,  in  water  at  a  temperature 
of  130°  to  150°  F.,  are  of  service  ;  but  when  cough,  distress  of 
breathing,  and  dysphagia,  due  to  narrowing  of  the  larynx,  ulcera- 
tion of  the  cords,  or  of  the  epiglottis,  occur,  all  inhalations  must 
be  of  the  most  soothing  nature. 

Plain  steam  of  water,  at  from  120°  to  140°  F.  ;  compound 
tincture  of  benzoin,  one  fluid  drachm  to  a  pint  of  water,  with  or 
without  three  to  five  drops  of  chloroform,  for  each  inhalation  ; 
pine  oil,  eucalyptus,  conium,  or  hop — are  to  be  recommended 
(Form.  29,  30,  31,  34,  36,  and  37). 

With  respect  to  the  last-named  remedy,  it  should  be  remem- 
bered that  the  oil  of  hop  is  very  stimulating,  not  to  say  irritating  ; 
while  the  extract,  with  a  little  carbonate  of  soda,  as  used  with 
the  extract  of  conium,  or  a  fresh  infusion,  is  most  soothing. 

Spray  inhalations,  as  employed  by  the  patient  for  several 
minutes  at  a  time,  are  of  but  little  use  in  laryngeal  phthisis; 
they,  as  a  rule,  involve  great  fatigue,  and  are  peculiarly  irritating 
to  the  mucous  membrane,  which  in  this  disease  is  unusually 
sensitive.  The  use  of  iodine  in  the  form  of  inhalation  is  also  to 
be  deprecated,  on  account  of  its  powerfully  irritant  properties. 

Scarification  is  of  most  doubtful  propriety  in  this  disease  :  the 
wounds  would  invariably  ulcerate,  and  the  operation  would 
certainly,  looking  at  the  very  solid  nature  of  the  thickening,  give 
but  a  minimum  of  relief. 

Still  greater  local  benefit  may  be  found  in  the  use  of  the  brush 
than  by  inhaling ;  and  here  again  it  is  encouraging  to  find 
Dr.  Williams  agreeing  in  condemnation  of  nitrate  of  silver. 
The  solutions  appropriate  to  the  pharyngeal  ulcerations,  as 
enumerated  on  page  220,  are  of  equal  utility  in  the  laryngeal 
disease.  Cocaine  lozenges  are  successful  in  relieving  the  pain  of 
swallowing,  but  their  effect  is  often  disappointing. 

Lozenges  containing  morphia  or  opium  are  of  the  greatest 
value  in  relieving  the  cough,  but  it  must  be  remembered,  in 


TUBERCULOUS  LARYNGITIS. 


421 


regard  to  them,  how  small  an  amount  of  opium  or  of  morphia, 
taken  in  a  lozenge  or  solution,  if  frequently  repeated,  will  have  the 
desired  effect  (Form.  16  and  19). 

All  food  should  be  of  the  blandest  character,  and  should  be 
taken  at  a  most  moderate  temperature.  It  will  often  be  prevented 
from  '  going  the  wrong  way'  if  the  patient  be  directed  to  thicken 
his  drink,  and  to  gulp  instead  of  sipping  it.  The  raw  egg 
swallowed  en  bloc,  as  previously  described  (p.  149),  will  be  found 
his  drink,  and  to  gulp  instead  of  sipping  it.  The  raw  egg  swal- 
lowed en  bloc,  as  previously  described  (pp.  147,  148),  will  be  found 
both  agreeable  and  nutritious  in  this  disease.  ^^Wolfenden  has 
published  the  following  simple  method,  learned  from  a  patient,  of 
obviating  difficulty  in  swallowing,  experienced  in  those  cases  in 
which  the  epiglottis  is  thickened  and  ulcerated.  The  patient, 
lying  on  a  couch  stomach  down,  and  with  the  legs  elevated,  sucks, 
by  means  of  an  india-rubber  tube,  fluid  from  a  tumbler  held  in  his 
hand.  The  advantage  of  this  method  has  been  repeatedly  con- 
firmed by  myself  and  many  other  practitioners. 

The  foregoing  represents,  with  but  slight  modification,  the  lines 
of  treatment  I  advocated  in  my  former  edition.  The  question 
once  more  occurs,  can  we  do  more  than  relieve  the  symptoms — 
can  we  arrest  or  cure  a  laryngeal  tuberculosis  ? 

With  rare  exceptions  the  combined  general  experience  of  spe- 
cialists has  hitherto  been  to  the  effect  that  although  a  tuberculous 
ulceration  in  the  throat  may  heal,  as  in  other  parts,  such  a  process 
is  certain  to  be  followed  sooner  or  later  by  an  outbreak  in  close 
proximity.  The  disease,  as  we  have  seen,  may  even  become 
chronic  and  lie  dormant,  of  which  state  Solis  Cohen  reports 
several  cases,  with  praiseworthy  further  narration  of  the  final 
result.  Writing  six  years  ago,  we  ventured  to  say  that  '  not 
even  the  most  sanguine  throat  specialist  is  yet  justified  in  giving 
even  a  moderately  hopeful  opinion  as  to  the  result '  of  any  known 
treatment.'  That  expression  was  received  with  general  favour, 
and  has  more  than  once  been  quoted.  The  question  is,  are  we 
able  to  modify  that  opinion  in  the  present  day  ? 

We  dismiss  from  consideration  treatment  by  iodide  of  potassium 
— stated  by  ^^Moritz  Schmidt  at  Milan,  in  1880,  to  be  efficacious 
in  curing  tuberculous  ulceration  in  the  larynx — since  we  have 
found  it  universally  baneful  rather  than  beneficial  in  our  personal 
practice,  in  undoubted  cases  of  laryngeal  phthisis  uncomplicated 
by  syphilis.  Nor,  from  our  experience  of  even  slight  scarifica- 
tions, can  we  subscribe  to  the  practice  of  deep  incisions  into  the 
infiltrated  tissues,  as  advocated  by  the  same  authority,  and  by 
^°E,ossbach. 

Our  brief  notice  at  page  221  of  the  more  recent  methods  of 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Krause  and  Rosenberg,  were  written  before  we  had  been  able  to 
give  them  anything  Hke  effective  trial ;  nor  are  we  yet  in  a  position 
to  speak  more  than  encouragingly  concerning  them.  In  a  paper 
read  by  ^4<rause  before  the  Laryngological  Subsection  of  the  fifty- 
ninth  meeting  of  German  Naturalists  and  Physicians  at  Berlin,  on 
September  21,  1886,  that  author  asserted  that  '  ulcers  of  the  pos- 
terior laryngeal  wall  are  curable  by  lactic  acid.  If  there  is  not 
too  much  marasmus,  which  is  a  contra-mdication,  no  tuberculous 
ulcer  can  resist  cicatrization  by  application  of  lactic  acid,  made 
by  a  practised  hand.  The  pain  or  even  a  certain  amount  of 
spasm  resulting  from  the  treatment  is  no  contra-indication.'  The 
success  of  this  measure  was  confirmed  by  such  eminent  authorities 
as  Schroetter  and  B.  Fraenkel.  Schnitzler,  at  this  meeting;  while 
admitting  that  laryngeal  phthisis  is  curable,  remarked  that  every 
new  medicament  has  had  its  temporary  successes,  and  he  believes 
iodoform  to  be  better  than  lactic  acid.  The  results  of  our  own 
practice  are  directly  opposed  to  this;  for  with  considerable  ex- 
perience, we  have  seen  no  benefit  whatever  from  either  insuffla- 
tions of  iodoform  in  powder  or  applications  of  it  in  solution. 

Hering,  of  Warsaw,  a  trustworthy  and  also  an  original  and 
bold  practitioner,  read  two  papers  on  the  sam.e  occasion,  ^  On  the 
Curability  of  Tuberculous  Laryngeal  Ulcers,  and  on  their  Treat- 
ment,' and  reported  that  '  he  had  seen  eight  unquestionable  cases 
which  prove  the  curability  of  tuberculous  ulcers.  He  had  also  seen 
cures  of  such  ulcers  without  medication.  The  ulcers  were  on  the 
true  and  false  ligaments,  pars  arytenoidei,  and  epiglottis.  Their 
tubercular  nature  was  certain  from  the  contemporaneous  affection 
of  the  lung,  and  the  presence  of  bacilli.  In  three  cases,  the  cure 
lasted  respectively  nine,  two,  and  one  years ;  and  in  five  cases 
half  to  three  years.  The  larynx  cured,  the  lung  is  ameliorated, 
the  voice  becomes  better,  and  general  improvement  results.' 

Early  in  1887  ^  exhibited  a  patient  at  the  Medical  Society 
treatevi  by  the  method  of  Krause,  the  details  of  whose  treatment 
in  every  respect  are  in  accordance  with  his  statements. 

It  is  that  of  Matilda  H.,  whose  history,  symptoms,  and  physical  evidences  in  throat 
and  chest  are  narrated  at  pp.  213  and  214,  and  I  append  copies  of  the  appearance 
sketched  on  her  case-paper  (Figs.  CXLIIl.  and  CXLIV.). 

It  will  be  observed  that  the  manifestations  were  in  this  case  in  the  very  situation 
remarked  by  Krause  as  favourable  to  treatment.  Having  applied  cocaine,  I  first  scraped 
the  parts  with  a  circular  curette — in  fact,  the  instrument  of  Lowenberg  for  removal  of 
post-pharyngeal  adenomata.  I  then  applied  on  a  cotton-wool  brush,  and  with  consider- 
able firmness,  a  20  per  cent,  solution  of  lactic  acid.  This  was  repeated  daily,  the  strength 
being  increased  to  40  per  cent,  and  60  per  cent.  At  the  end  of  three  weeks  acute  inflam- 
mation of  the  pharynx  and  larynx  took  place  ;  but,  as  asserted  by  Krause,  the  plan  was 
no  contra-indication  to  success,  for  on  recovery  the  parts  cicatrized  healthily,  and  not  only 


TUBERCULOUS  LARYNGITIS. 


423 


was  the  extreme  odynphagia  which  had  been  experienced  on  admission  completely 
relieved,  but  weii;ht  was  regained,  and  the  pulmonary  condition  imjDroved.    It  only 


Fig.  CXLTII.— Pharyngeal 
Appearance. 


Fig.  CXLIV. — Laryngoscopic 
Image. 


remains  to  add  that  the  patient  is  still  alive  and  in  fair  health,  Feb.  1890. 

All  my  colleagues  are  equally  enthusiastic  with  me  in  experi- 
ments with  this  method  of  Krause,  and  we  have  kept  careful 
record  of  each  case  treated.  We  have  not  found  the  lactic  acid 
beneficial  in  purely  laryngeal  cases,  and  believe  that  the  20  per 
cent,  solution  of  menthol  in  olive-oil,  as  recommended  by  ^^Rosen- 
berg, is  decidedly  of  greater  value  in  those  conditions.  Menthol 
is  also  most  useful  as  an  oro-nasal  inhalant  and  stimulant  in 
the  anaemic,  and  as  a  sedative  in  the  later  stages.  Since  the 
publication  of  the  former  edition  we  have  had  several  cases  as 
strikingly  relieved  as  the  one  quoted ;  and  we  have  seen  many  in 
which,  after  a  few  days  of  treatment,  emaciation  has  been 
arrested,  deglutition  improved,  cough  and  amount  of  local  secre- 
tion diminished,  and,  lastly,  an  actual  regain  of  lost  weight. 
It  is  also  right  to  add  that  in  every  case  we  urge  employment, 
for  at  least  twelve  hours  a  day,  of  the  oro-nasal  inhaler  with  the 
inhalants  in  Form.  41,  52,  and  55,  or  with  menthol,  and  to  this 
measure  we  attach  great  importance. 

I  am  not  of  opinion  that  the  exact  mode  in  which  the  applica- 
tion is  made  to  the  larynx  influences  the  result ;  but  Bosworth,  who 
for  many  years  has  claimed  a  large  proportion  of  cures,  or  at  least 
of  arrest  of  the  tuberculous  process  in  the  larynx,  lays  great  stress 
on  the  use  of  the  spray,  locally  directed  by  the  physicians  with 
the  aid  of  the  mirror.  Personally,  I  have  doubts  if  by  this  method 
the  application  reaches  to  ventricles,  etc.,  so  completely  as  by  a 
soft  brush  made  of  absorbent  wool,  and  only  moderately  charged 
with  the  solution.  This  view  has  been  enforced  by  ^*Roe  ;  but  it 
appears  to  me  that  there  is  also  an  additional  objection  to  the 
direct  treatment  of  laryngeal  diseases  by  means  of  sprays  and 
syringes,  in  that  solutions  of  considerable  strength  make  their 
entrance  into  the  subglottic  region  with  greater  force  and  in 
larger  quantity  than  is  the  case  when  a  brush  is  applied.    As  a 


424 


DISEASES  OF  THE  THROAT  AND  NOSE. 


result,  there  is  considerable  danger  of  destroying  the  cilia  of  the 
trachea  and  bronchi,  and  of  increasing  the  tendency  to  catarrhal 
inflammations  of  those  canals.  In  the  use  of  lactic  acid  there 
cannot  be  a  doubt  that  some  amount  of  distinct  friction  is  neces- 
sary, but  the  application  should  always  be  localized  to  the  exact 
part  implicated.  Before  the  solution  is  employed  the  ulcer  should 
always  be  carefully  but  thoroughly  scraped  by  a  curette. 

Tracheotomy. — In  my  former  edition  I  spoke  very  unfavour- 
ably of  the  operation  on  patients  who  are  the  subjects  of  laryngeal 
phthisis,  and  I  am  not  now  prepared  to  admit  that  it  is  advisable, 
except  in  rare  instances,  and  to  relieve  extreme  symptoms  of  a 
suffocative  character ;  for  it  should  be  borne  in  mind  that  in  this 
disease  the  whole  mucous  membrane  is  most  sensitive  to  irritation, 
and  is  strongly  disposed  to  ulceration,  and  that  the  cartilages  of 
the  larynx  and  trachea  are,  if  not  actually  degenerated,  most 
prone,  with  the  least  aggravation,  to  caries.  It  is  therefore 
extremely  doubtful  whether  presence  of  a  tracheotomy-tube  does 
not,  in  such  a  case,  actually  increase  the  embarrassment  of  both 
respiration  and  deglutition.  At  the  most,  it  can  but  prolong  life 
a  few  days  or  weeks,  with  but  little,  if  any,  amelioration  of  dis- 
tressing symptoms,  while  in  one  direction,  as  pointed  out  by 

Percy  Kidd,  the  distress  of  cough  is  distinctly  increased,  thii 
presence  of  the  tracheotomy-tube  making  the  act  of  coughing 
much  more  difficult,  and  even  impossible. 

Early  tracheotomy  has  been  advised  in  this  disease  on  the  two- 
fold plea  (i)  that  the  disease  may  be  primary,  and  that  by 
tracheotomy  the  lungs  will  be  less  liable  to  be  infected  ;  and  (2) 
that  functional  rest  is  hereby  afforded  to  the  larynx,  and  a  better 
chance  given  of  success  by  topical  medication.  Curiously  enough, 
it  has  to  be  added  that  one  of  the  strongest  advocates  of  trache- 
otomy in  laryngeal  phthisis,  Beverley  Robinson,  of  New  York, 
has  also  maintained  that  a  laryngitis  occurring  in  the  course  of  a 
pulmonary  phthisis  is  not  necessarily,  nor  indeed  frequently,  of 
itself  tuberculous,  but  is  to  all  intents  and  purposes  of  the  essence 
of  an  ordinary  catarrh.  Answering  the  first  of  these  pleas,  the 
probability  of  the  tuberculous  disease  being  primary  in  the  larynx, 
I  have  to  say  that  though  I  for  many  years  believed  in  the  possi- 
bility of  a  primary  tuberculosis  of  the  larynx,  before  it  was  actually 
demonstrated  as  a  fact,  I  cannot  agree  that  such  a  circumstance 
is  other  than  rare  in  medical  experience.  And  as  to  the  second, 
I  am  not  at  all  prepared  to  admit  that  absolute  rest  of  the  lar_vnx 
is  likely  to  follow  a  tracheotomy  on  a  tuberculous  patient,  what- 
ever the  stage ;  on  the  contrary,  in  no  disease  is  a  tube  so  ill- 
borne  or  so  liable  to  set  up  increased  inflammatory  irritation  and 
ulceration.    Moreover,  in  no  disease  is  more  likely  to  occur  the 


TUBERCULOUS  LARYNGITIS, 


425 


untoward  risk  of  what  we  may  call  collapse  of  the  larynx — a  not 
unfrequent  result  of  tracheotomy — which  was  first  pointed  out  by 
Liston,  and  has  since  been  insisted  on  by  Whistler.  Nor  can  I 
agree  that  the  larynx  can  be  more  effectively  treated  by  topical 
measures  after  tracheotomy  than  before,  for,  on  account  of  the 
disposition  to  collapse  just  mentioned,  the  larynx  is  almost  invari- 
ably far  more  difficult  to  examine,  as  also  to  be  treated  internally, 
after  a  tracheotomy-tube  has  been  introduced. 

Tracheotomy  is  advocated  by  ^"Moritz  Schmidt  on  the  ground 
that  it  not  only  betters  respiration — to  the  lungs  I  presume — but 
also  that  it  deviates  from  the  larynx  the  passage  of  irritating  air — 
to  which  it  has  only  to  be  replied  that  by  use  of  oro-nasal  inhalers 
and  suitable  atmospheres,  the  air  to  the  larynx  can  readily  be 
made  non-irritating,  and  even  beneficial,  and  this  to  a  greater 
extent  than  can  be  provided  for  in  the  air  which  goes  to  the  lungs 
through  a  tracheotomy-tube. 

But  the  operation  is  also  performed  by  Schmidt,  by  Heryng, 
and  by  Gouguenheim  and  Tissier,  not  only  where  the  laryngeal 
disease  is  marked  and  advancing,  but  in  cases  in  which  the  lungs 
are  admittedly  affected.  The  last-named  joint  authors,  in  their 
recently-published  classical  treatise,  hold  that  even  extensive 
disease  of  the  lungs  does  not  contra-indicate  the  operation,  if  the 
temperature  be  not  high,  and  digestion  be  good — to  which  condi- 
tion I  cannot  assent,  for  a  comparatively  low  temperature  in 
laryngeal  phthisis  is  by  no  means  a  favourable  indication,  while  a 
good  digestion  is  a  circumstance  hardly  ever  likely  to  be  afforded 
us  as  a  factor  for  consideration  in  this  disease,  and  certainly  not 
in  advanced  cases. 

I  must,  therefore,  with  all  respect  to  the  many  able  laryngo- 
logists  who  advocate  tracheotomy  in  tuberculous  laryngitis,  offer 
my  uncompromising  opposition  thereto,  hardly  excepting  cases  of 
urgent  dyspnoea,  in  which  it  is  considered  as  permissible  by  Solis- 
Cohen,  Morell  Mackenzie,  and  Krishaber.  I  certainly  would  not 
perform  it,  except  at  the  request  of  the  patient  or  his  friends,  and 
not  even  then  without  very  plainly  stating  that,  although  death 
by  actual  suffocation  might  be  thereby  averted,  life  would  hardly 
be  prolonged,  and  that  only  at  some  considerable  expense  of 
suffering  and  lingering  distress.  I  think  also  that  we  ought  to 
bear  in  mind  that  performance  of  tracheotomy  in  a  case  of 
advanced  tuberculous  disease  is  likely  to  bring  both  the  operation 
and  the  surgeon  who  performs  it  into  disrepute ;  for,  as  to  the 
operation,  an  unfavourable  result  in  one  case  may  militate  against 
consent  being  given  to  its  performance  in  another,  where  chances 
of  permar.ent  relief  might  be  good;  and  as  to  the  operator, 
especially  if  he  be  a  specialist,  there  will  not  unhkely  be  found  a 


426 


DISEASES  OF  THE  THROAT  AND  NOSE. 


medical  brother  (save  the  mark  !)  who  will  speak  of  tracheotomy 
having  been  performed  by  one  who  would  not  or  could  not  look 
beyond  the  narrow  area  of  his  special  province. 

REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

400 

Browne  and  Grant. 

400 

2 

Demme. 

401 

3 

Reverley  Robinson. 

401 

4 

Gottstein. 

402 

5 

Heinze. 

404 

6 

Sir  James  Sawyer. 

AOA 

7 

SoLis  Cohen. 

8 

Gougenheim. 

404 

9 

Fraenkel. 

10 

John  N.  Mackenzie. 

403 

II 

G.  Hunter  Mackenzie 

407 

12 

John  N.  Mackenzie. 

407 

13 

"c  •• 

oTOERK. 

407 

14 

Mandl. 

407 

15 

KOHNHORN. 

407 

16 

Lennox  Browne. 

414 

17 

BOSWORTH. 

414 

T  Q 

Beverley  Robinson. 

415 

19 

Moure. 

415 

20 

Von  Ziemssen. 

415 

21 

Poore. 

415 

22 

SoLis  Cohen. 

416 

23 

Morell-Mackenzie. 

416 

24 

416 

J 

419 

26 

Kremianski. 

419 

27 

Reynolds. 

421 

28 

Wolfenden. 

421 

29 

MoRiTZ  Schmidt. 

421 

30 

ROSSBACH. 

422 

31 

Krause. 

422 

32 

Hering. 

423 

33 

Rosenberg. 

423 

34 

J.  0.  Roe. 

424 

35 

Percy  Kidd. 

424 

36 

Beverley  Robinson. 

425 

37 

Schmidt. 

TITLE  OF  work  REFERRED  TO. 


Archives  of  Lary myology,  vol.  ii.,  No.  1. 

New  York,  1881. 
Bericht  iiber  die  Thdtigkeit  des  Jenner- 
shen  Kinder spitais.     Berne,  1883. 
Quoted  in  Centralbldtt  fiir  Laryngol., 
p.  213.  January,  1885. 
The  Laryngeal  A  ffections  of  Pulmonary 
J'hthisis,  Archives  of  Laryngology, 
vol.  ii.,  p.  300  et  seq. 
Op.  cit.,  p.  205. 

K  Die  ICehlkopfschwindsucht.  etc.  Leip- 
j     zig,  1879. 
The  Lancet,  Jan.  30,  1875,  and  Con- 
tributions to  Practical  Medicine,  p.  25. 
Birmingham,  1886. 
Arner.  Jo  urn.  Med.  Sciences.    Jan.,  1 88  3. 
j  VCEdeme  Laryngien  dans  la  Tuber- 
\     culose  du  Larynx.    Paris,  1884. 
Virchow's  Archiv,  Ixxi.,  3.  1877. 

Med.  Chir.  Transactions .  Maryland, 
April,  1882. 
Edinburgh  Medical Journ.,  Feb.,  1 884. 
\  Archives  of  Medicine,  No.  2,  vol.  viii. 
f     Oct.,  1882. 
\0p.  Cit.,  p.  282. 
Op.  cit.,  p.  688. 

Berlin  Klin.  Woch.,  Nos.  3  and  4,  1876. 
Traiisactions  of  Path.  Society, \d\.  xxvii., 
p.  51.    London,  1876. 
Archives  of  Laryngology,  vol.  ii. ,  p.  332. 
Lbid.,  p.  309. 

j  De  la  Syphilis  et  de  la  Phthise  Laryngees^ 

{     etc.    Paris,  1879. 
Encyclopcedia  of  Medicine,  vol.  viii. ,  p.  848. 
\Lancet,  p.  83.    July  17,  1880. 

K  Diseases  of  the  Throat,  2nd  edition,  p. 

\     512.    New  York,  1879. 
op.  cit.,  p.  375. 

System  of  Medicine^  vol.  iii.,  p.  460. 
Sciefice  of  Medicine,  vol.  ii.,  p.  712. 
Lancet,  March  5,  1887. 
Lbid.,  March  19,  1887. 
Lancet.    July  2,  1887. 
Comptes  Rendus  djt  Congres  ii  Milan,  i  SSo. 
Trans.  Internat.  Med.  Congress,  y>.  212. 
1881. 

Revue  Mejisuelle  de  Laryngologie,  etc. , 

p.  626.    Nov.,  1886. 
Lbid.,  pp.  625  and  627.  Also  No.  7,  pp. 
385  and  387.    July,  1886. 
Ibid.,  p.  627.    Nov.,  1566. 
Arcliives  of  Lary7jgology,  vol.  iii.  1882. 
Lancet.    March  31,  1888. 

Value  of  Rest  in  Laryngeal  Diseases: 
Archiv.  of  LarynqoL,  vol.  i.,  p.  250. 
1880. 

Revue  Mensuellc,  etc.,  p.  626.  Nov.,  1886. 


CHAPTER  XX. 


LUPUS  AND  LEPROSY  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX. 

(Fig.  119,  Plate  XIV.) 

[It  has  been  thought  convenient  to  treat  all  these  conditions  under  one  heading,  but  in 
view  of  the  greater  importance  of  the  laryngeal  manifestations,  discussion  of  those  in  the 
other  regions  of  the  throat  has  been  postponed  from  the  position  they  should  occupy 
according  to  the  plan  of  this  volume.] 

At  the  time  of  writing  my  first  edition  I  had  not  seen  a  case  of 
lupus  in  the  throat,  and  at  the  date  of  its  pubHcation  there  were 
only  nine  cases  on  record,  of  which  at  least  three  were  doubtful. 
Just,  however,  at  that  period  ^Lefferts  contributed  an  important 
essay  on  this,  as  it  was  then  considered,  rare  disease,  with  a  care- 
fully recorded  case  which  had  occurred  in  his  own  practice.  He 
it  was  who  first  suggested  that  lupus  of  the  throat  would  be  found 
to  be  much  less  rare  than  had  hitherto  been  supposed,  if  it  were 
looked  for  in  all  subjects  presenting  cutaneous  manifestations. 
Until  then  only  patients  who  complained  of  laryngeal  symptoms 
vvere  inspected  with  the  laryngoscope  in  the  Skin  Clinic  of  Vienna, 
and  of  the  whole  number  thus  examined  the  proportion  that  afforded 
evidence  of  lupus  in  the  larynx  was  only  8  per  cent. ;  but  systematic 
laryngoscopic  observation  of  every  patient  with  lupus  by  ^Chiari 
and  Riehl  showed  that  the  larynx  was  affected  in  as  many  as  six 
cases  out  of  sixty — 10  per  cent.  ^Holm,  of  Copenhagen,  found 
disease  in  the  larynx  in  six  cases  out  of  ninety  with  the  general 
disease.  These  combined  investigations  give  a  proportion  of 
about  8  per  cent,  of  laryngeal  manifestations  in  150  patients 
suffering  from  lupus  of  other  parts  of  the  body  ;  and  the  figures 
agree  closely  with  my  own  experience. 

Through  the  kindness  of  Drs.  Harries  and  Campbell  I  had  an  op- 
portunity, in  the  summer  of  1886,  of  examining  the  throats  of  twenty- 
five  patients  suffering  from  lupus,  who  were  at  that  time  attending 
St.  John's  Hospital  for  Diseases  of  the  Skin.  I  found  laryngeal 
changes  in  three  cases ;  in  one  of  these  there  was  also  ulceration 


428 


DISEASES  OF  THE  THROAT  AND  NOSB. 


of  the  velum.  But  I  discovered  palatal  evidences  in  three  others  ; 
so  that  one-fifth  of  the  cases,  or  20  per  cent.,  were  the  subject  of 
either  faucial  or  laryngeal  manifestations,  while  the  latter  only 
were  present  in  12  per  cent. ;  the  same  proportion  as  was  ob- 
served by  Chiari  and  Riehl.  Strange  to  say,  though  the  voice  was 
more  or  less  hoarse,  thick,  or  nasal  in  every  one,  in  not  a  single 
instance  was  there  complaint  of  difficulty  in  either  deglutition  or 
respiration.  This  circumstance  illustrates  an  important  diagnostic 
element  of  the  disease,  namely,  that  the  functional  symptoms  are 
as  a  rule  very  slight  even  in  the  presence  of  long-standing  manifes- 
tations. In  addition  to  the  foregoing  cases,  to  all  of  which  more 
detailed  allusion  will  be  presently  made  and  their  throat  appear- 
ances portrayed,.  I  have  seen  three  other  cases  with  laryngeal 
manifestations,  and  one  with  solely  palatal  changes ;  I  have  also 
had  the  opportunity  of  studying  a  fifth  under  the  care  of  my 
colleague.  Dr.  Orwin.  Thus,  in  twenty  years  of  special  throat 
practice,  I  have  seen  fewer  laryngeal,  and  still  fewer  palatal, 
cases  of  lupus,  than  I  saw  at  a  Skin  hospital  in  a  few  weeks. 

^Lefferts  goes  so  far  as  to  affirm  that  '  he  would  not  accept  the 
diagnosis  of  lupus  of  the  larynx  or  pharynx,  unless  accompanied 
by  lupus  of  th^  face.'  Without  doubt  such  an  association  is  the 
rule,  but  quite  a  number  of  cases  have  been  recorded  in  which  the 
laryngeal  disease  has  preceded  the  cutaneous.  Some  of  them  are 
admittedly  equivocal,  notably  the  well-known  one  of  ^Von 
Ziemssen. 

*^  Morris  Asch,  of  New  York,  in  an  able  essay  on  the  disease, 
full  of  interesting  bibliographical  history,  has  reported 

the  case  of  a  young  girl,  aged  18,  suffcilng  from  ulceraLion,  which  he  beheved  to  be  true 
lupus,  occurring  simultaneously  in  the  larynx  and  pharynx  ;  but  there  was  already  on  the 
posterior  wall  of  the  pharynx  a  large  radiated  cicatrix,  of  the  origin  of  which  the  patient 
could  give  no  history.  .  .  .  Examination  of  the  surface  of  the  body  discovered  no 
cutaneous  lesion,  eruption,  or  enlarged  glands,  and  the  closest  inquiry  failed  to  reveal  any 
antecedent  syphilitic  history,  inherited  or  otherwise.  The  patient  was  a  tall  slender 
blonde,  of  the  type  with  which  we  are  accustomed  to  associate  strumous  disease. 
The  condition  of  the  teelh  is  not  noted. 

Lefferts,  in  discussion,  expressed  his  opinion  that  this  case  was 
one  of  inherited  syphilis,  and  undoubtedly,  in  the  absence  of 
cutaneous  corroboration,  the  diagnosis  is  not  easy ;  but  the  follow- 
ing case  is  in  every  respect  very  similar,  with  the  exception  that 
confirmation  of  this  character  did  not  occur  till  six  years  after  the 
throat  affection. 

The  case  is  inserted  by  the  kind  permission  of  Dr.  Orwin, 
whose  patient  she  is. 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  429 


Case  I. — Maggie  N.,  a  fair  girl,  aged  21,  from  Northampton,  first  attended  at  the  Central 
Throat  and  Ear  Hospital  on  September  nth,  1886.  She  gave  the  following  history  : 
when  n  years  old  had  bronchitis  with  ulcerated  throat.  She  was  ill  for  six  months. 
Since  that  period  she  has  had  fairly  good  health,  but  has  always  been  conscious  of  a 
slight  wheezing  sound  in  her  breathing.  She  did  not  apply  on  account  of  her  throat,  as 
'  she  reckoned  that  well,'  but  for  the  disease  of  her  nose  (Fig.  CXLV.),  which  presented 
all  the  characters  of,  and  was  at  once  diagnosed  as,  h(pi/s  milgaris. 

By  reference  to  the  illustration, 
it  will  be  noticed  that  the  disease 
had  also  attacked  the  coverings  of 
the  alveolar  processes  of  the  upper 
jaw.  The  gums  were  almost  taten 
away,  and  as  a  consequence  the 
upper  teeth  had  an  abnormally 
long  and  projecting  appearance  ; 
otherwise  they  were  well  formed 
and  free  of  any  characteristics  of 
syphilis  or  scrofula.  The  gums 
had  been  first  affected  more  than 
four  years  previously,  and  the 
erosion  was  stated  to  have  been 
very  gradual.  The  disease  of  the 
nostril  cotiunenced  sotne  months 
later,  and  the  patciies  on  the  cheek 
still  more  recently.  The  family 
history  was  good,  and  the  general 
health  and  nutrition  of  the  patient 
were  excellent. 

The  voice  of  this  patient  is 
but  slightly  modified  in  phonetic 
quality  ;  articulation  is  nearly  per- 
fect, perhaps  a  little  altered  by  the 
condition  of  the  teeth  and  gums,  and  sometimes  it  is  a  trifle  nasal  in  character.  The 
respiration  is  slightly  wheezing  ;  the  sound  being  laryngeal  during  inspiration,  and  nasal 
during  expiration.    There  has  never  been  any  dyspnoea  or  increase  of  stridor,  and  she 


Fig.  CXLV. — Lupus  of  the  Nose  and 
Upper  Gums. 


Fig.  CXLVL— Condition  of 
THE  Pharynx. 


Fig.  CXLVIL — Condition  of  the 
Larynx. 


can  run  up  and  down  stairs  without  distress.  There  is  no  cough  ;  deglutition  is  quite 
normal,  and  there  is  no  disorder  in  the  senses  of  hearing,  of  smell,  or  of  taste. 

On  examination  of  the  pharynx  (Fig.  CXLVL)  it  is  seen  that  the  whole  of  the  uvula 
and  a  portion  of  soft  palate  and  of  the  pillars  of  the  fauces  have  been  destroyed,  and 


430 


DISEASES  OF  THE  THROAT  AND  NOSE. 


there  is  a  stellate  scar  above  the  situation  of  the  uvula.  The  hard  palate  l.ad  been  un- 
touched by  disease.  The  posterior  wall  of  the  pharynx  is  somewhat  more  granular  than 
normal,  and  certainly  more  so  than  in  tertiary  syphilis. 

The  laryngoscope  -.howed  a  very  peculiar  condition  (Fig.  CXLVII.,  and  Fig.  119, 
Plate  XIV.).  The  whole  mucous  membrane  is  markedly  pale,  and  of  an  opaque  warm 
greyish  tone.  There  is  no  sign  of  any  active  inflammation,  and  on  touching  the  surface 
sensibility  is  found  to  be  diminished.  The  epiglottis  is  almost  entirely  destroyed,  and  is 
represented  by  several  tight  cicatricial  bands  which  are,  as  it  were,  hypertrophied  sub- 
stitutes for  the  ordinary  epiglottic  ligamentous  attachments  to  the  tongue  and  pharynx. 
The  undei  surface  or  cushion  is  continuous  in  plane  with  the  ventricular  bands,  which  in 
turn  are  merged  into  the  ary-epiglottic  folds. 

In  the  centre  is  observed  a  small  opening  that  will  not  admit  an  instrument  of  the 
size  of  a  goose-quill.  This  orifice  is  evidently  on  a  level  superior  to  the  vocal  cords 
which,  from  the  tone  of  the  voice,  appeared  to  be  quite  unaffected.  There  is  no 
hypertrophy  of  the  papillae  of  the  base  of  the  tongue. 

The  patient  was  exhibited  by  Dr.  Orwin  at  the  Medical  Society 
of  London  in  November,  1886,  when  she  was  seen  by  many 
speciahsts,  who  agreed  in  the  diagnosis  of  lupus ;  but  had  it  not 
been  for  the  cutaneous  evidence  which  was  only  afforded  six  years 
after  the  ulceration  in  the  throat,  there  can  be  no  doubt  that  this 
case  would  have  been  set  down  as  one  of  syphilis,  or  at  least  as 
one  of  scrofulous  lupus,  described  by  ^Homolle,  and  acknowledged 
as  a  separate  variety  by  Lefferts.  I  see,  however,  no  useful  object 
to  be  gained  by  adoption  of  such  a  subdivision. 

^Knight,  of  Boston,  has  recorded  three  cases  : 

His  first  has  many  points  of  striking  similarity  to  the  foregoing,  but  the  throat  was 
affected  subsequently  to  the  face. 

In  his  second,  the  patient — a  married  female,  36  years  old — had  scarlatina  at  8  years 
of  age,  serious  throat  trouble  of  the  nature  of  lupus  at  25,  a^a  ulceration  of  the  skin  of 
the  nose  at  28,  '  after  ulceration  of  the  throat.'  In  speaking  of  this  case  in  discussion, 
the  author  had  no  doubt  that  it  '  was  a  genuine  one  of  lupus,  and  the  lesions  upon  the 
skin  confirmed  this  view ;  certainly  the  manifestations  appeared  too  late  to  be  considered 
as  due  to  congenital  syphilis,  and  acquired  disease  was  out  of  the  question.' 

The  only  element  of  doubt  is  that  there  was  necrosis  of  the  hard 
palate — a  circumstance  incompatible  with  the  generally  admitted 
fact  that  the  ulceration  of  lupus  may  extend  to  muscles,  tendon, 
and  cartilage,  but  that  it  stops  short  at  bone.  Knight's  third 
case  is  one  which  he  believes  to  have  been  lupus  of  the  pharynx, 
without  manifestation  elsewhere. 

Consideration  of  all  the  foregoing  cases,  as  well  as  of  others 
of  a  similar  character,  reported  by  competent  observers,  and 
especially  of  that  of  Dr.  Orwin,  must  force  us  to  the  conclusion 
that  lupus  may  exist  in  the  throat  without  external  manifestations, 
or  long  prior  to  the  same  ;  and  that,  though  such  a  circumstance 
is  undoubtedly  exceptional,  it  is  just  one  of  those  exceptions  to  a 
rule  which,^as  Sir  James  Paget  has  recently  said  so  wisely,  may 
be  in  fact  but  the  beginning  of  a  new  law. 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  43^ 


Etiology. — Lupus  has  been  generaily  considered  by  English 
and  French  dermatologists  as  evidence  of  a  scrofulous  taint — a 
term  which  is,  for  the  most  part,  very  loosely  applied.  Without 
doubt  it  often  represents  a  euphonious  synonym  for  syphilis,  and 
is  indeed  so  employed  by  ^Erasmus  Wilson  in  connection  with 
this  very  disease.  Others — ^^Pye  Smith,  for  example — think  that 
'  the  whole  process  is  strikingly  similar  to  that  which  occurs  in  the 
lungs  during  the  course  of  phthisis.* 

I  think  everyone  will  admit  that  the  general  characters  of  lupus 
are  more  nearly  aUied  to  those  of  tubercle  than  of  syphilis;  but  the 
sthenic  character  of  the  constitutional  state  is  as  strikingly  dif- 
ferent from  the  first,  as  is  the  fact  that  anti-syphilitic  (mercurial) 
treatment  in  true  lupus  does  but  aggravate  the  malady,  a  dis- 
tinctive feature  of  the  second.  German  authorities,  while  repelling 
the  scrofulous  theory,  offer  nothing  better  as  an  etiological  substi- 
tute. i^Gottstein  expresses  the  general  opinion  that  '  the  causes 
of  laryngeal  lupus  are  similar  to  those  influencing  the  disease  in 
other  parts,  or,  in  other  words,  often  unknown.' 

^"Harries  and  Campbell,  in  a  recently  published  joint  contribu- 
tion of  high  clinical  value,  thus  summarize  : 

'  In  order  that  this  disease  may  develop  there  will  be  needed — 

'  (a)  Suitable  Soil,  whose  exact  characters  we  are  as  yet  unable 
to  define  ;  which,  though  possibly  alUed  to  tuberculosis  and  scro- 
fula, is  yet  not  identical  with  either. 

'  {b)  A  Predi'sposing  Cause. — Traumatism,  at  some  period  perhaps 
remote,  being  the  most  important. 

'  (c)  An  Exciting  Cause. — Probably  a  micro-organism.' 

As  to  the  first  of  these  factors  there  is  nothing  more  to  be 
said  ;  as  to  traumatism,  Virchow  has  defined  scrofula  as  '  vulnera- 
bility,' by  which  he  means  a  tendency  to  react  on  slight  injuries, 
and  difficulty  in  recovering  from  them  ;  and  undoubtedly  this  in- 
fluence is  very  frequent  in  lupus.  In  one,  that  of  J.  V.  (No.  8), 
to  be  presently  described,  injuries  were  the  cause  not  only  of  the 
first  manifestation  on  the  face,  but  of  several  later  ulcerations  in 
remote  portions  of  the  body.  What  is  the  immediate  cause  of  lupus 
in  the  throat  it  is  difficult  to  say.  In  one  of  Knight's  cases  scarla- 
tina is  suggested.  In  others  it  may  be  due  to  auto-inoculability, 
which  is  an  undoubted  feature  of  lupus.  Whether  in  these  cases 
there  is  a  slight  scratch  or  abrasion  on  the  gums  or  soft  palate  in  the 
first  instance,  or  whether  it  be  due  to  the  transplantation  on  a 
wounded  or  unwounded  surface  of  a  micro-organism,  I  do  not 
presume  to  decide ;  but  with  regard  to  the  presence  of  germs  as  an 


432 


DISEASES  OF  THE  THROAT  AND  NOSE, 


exciting  cause,  it  is  by  no  means  clearly  proved  that  they  are 
more  than  secondary  concomitants.      Campbell,  in  the  '  Essays  ' 
referred  to,  has  discussed  this  question  at  great  length  and  with 
impartiality.    While  admitting  that  they  are  possibly  pathogenic, 
he  is  forced  to  admit  that  '  so  far  as  we  can  gather  from  the 
works  quoted,  lupus  bacilli  have  only  been  observed  in  cases 
where  ulceration,  actual  or  incipient,  existed.    Nevertheless,'  he 
continues,  '  we  may  be  justified  in  stating  that  lupus,  whether 
ulcerating  or  not,  is  probably  coincident  with  the  presence  of 
bacilli  in  the  diseased  tissue.'    It  may  just  be  stated  further  that 
while  some  investigators — Koch,  for  example,  and  also  ^^Nelsser 
— contend  that  the  bacillus  of  lupus  is  identical  with  that  of  tuber- 
culosis ;  others,  including    Kaposi,  ^^Schwimmer,  and  Campbell, 
affirm  that  there  is  no  such  similarity  or  identity. 

Lupus  of  the  throat,  as  in  the  skin,  is  more  common  in  females 
than  in  men,  and,  as  a  rule,  is  more  often  seen  in  the  lower  than 
the  upper  classes  of  society. 

An  exception  to  this  rule  was  seen  in  the  first  instance  of  lupus  in  the  larynx  which 
occurred  in  my  own  practice.  The  case  (No.  2)  was  that  of  a  lady,  aged  about  48,  who 
was  sent  to  me  in  November,  1879,  by  Dr.  Poyet,  of  Paris,  on  account  of  lupus  in  the 
larynx,  which  was  manifested  in  the  form  of  considerable  hypersemia  and  nodulation  of 
the  epiglottis,  and  ulceration  of  the  right  ary-epiglottic  fold.  She  was  the  subject  of 
four  or  five  patches  on  various  parts  of  the  body,  one  on  the  neck  just  under  the  right 
angle  of  the  jaw,  for  which  she  was  concurrently  treated  by  3Ir.  Jonathan  Hutchinson. 
The  disease  had  existed  for  about  three  years,  and  no  cause  could  he  ascertained  for 
its  origin.  The  patient  was  considered  to  be  of  a  gouty-rheumatic  diathesis,  and  had 
twice  undergone  a  '  cure  '  at  Aix-les-Bains  for  sciatica.  She  was  above  average  height, 
well  nourished,  and  the  mother  of  two  healthy  and  exceptionally  handsome  daughters. 
The  husband  was  also  tall  and  strong,  and  was  most  positive  in  his  denial  of  any  venereal 
history. 

It  is  worthy  of  remark  that  while  under  treatment  this  lady  fell  downstairs  and  cut  her 
face.    The  wound,  which  required  sutures,  healed  well  and  quickly. 

The  disease  is  said  to  be  most  commonly  manifested  in  youth. 
The  ages  of  the  eleven  patients  seen  by  me  have  been  21,  48,  43, 
46,  20,  17,  8,  24,  23,  16,  and  ig.  In  twenty-three  cases  observed 
by  Homolle,  eighteen  occurred  before  the  age  of  20.  His  ob- 
servations are  in  accordance  with  those  of  Hebra  regarding  the 
general  malady,  but  are  contravened  by  ^^Ramon  de  la  Sota  in 
connection  with  the  region  now  under  consideration ;  he  distinctly 
says  that  he  has  seen  lupus  in  the  throat  in  adults  oftener  than  in 
children,  and  oftener  in  men  than  in  women.  This  author  does 
not  believe  that  '  any  local  agencies  whatever  are  to  be  considered 
as  especially  prone  to  produce  the  disease.' 

Finally,  it  may  be  mentioned  that,  with  one  exception  (No.  11), 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  433 


all  the  cases  I  have  seen  in  the  throat  have  occurred  to  persons 
of  fair  complexion,  with  li^ht  or  light-brown  hair,  and  with  blue  or 
grey  eyes ;  in  fact,  in  those  recognised  as  of  lymphatic  temperament. 

Pathology. — This  has  been  discussed  to  some  extent  in  my 
remarks  on  Etiology,  and  there  is  nothing  specially  distinctive  in 
the  characters,  either  macro-  or  microscopical,  of  the  disease  in 
the  throat.  The  surface  appearances  will  be  best  given  under  the 
head  of  objective  or  physical  signs,  and  I  need  only  express  my  agree- 
ment with  Lefferts  that  the  first  essential  pathological  element  is 
hypertrophy  of  tissue — a  hyperplasia  and  infiltration  that  changes 
to  a  marked  degree  the  normal  configuration  of  the  part.  The 
second  element  is  the  ulceration,  which  is  always  slow,  is  very 
destructive,  but  much  more  gradual  and  less  actively  inflammatory 
than  syphilis  when  it  attacks  the  soft  palate,  while  in  the  larynx  it 
partakes  of  the  worm-eaten  character  of  phthisis,  indicating  that 
it  commences  in  the  glandular  and  inter-glandular  tissues.  The 
resulting  cicatrization  is  exceedingly  hard  and  unyielding  ;  it  is 
accompanied  by  hyperplasia  that  tends  to  form  contracting  bands 
and  to  constrictions  rather  than  to  the  formation  of  outgrowths. 
A  pathological  feature  of  distinction  is  the  occasional  occurrence 
of  fresh  granulations  on  cicatrized  tissue.  In  the  mouth  it  is 
evidenced  by  much  granulation  on  the  gums. 

Chiari  and  Riehl  describe  laryngeal  lupus  as  beginning  with  development  of  single 
jxipillary  growths,  varying  in  prominence  and  size  (from  a  millet  to  a  hemp-seed),  as  is 
the  case  in  other  mucous  membranes  ;  these  either  remain  single  or  appear  in  crowded 
groups  on  the  slightly  hyperseir.ic  mucous  membrane.  The  groups  increase  either  in  the 
neighbourhood  of  or  on  the  parts  first  affected,  both  in  extent  and  prominence,  so  that  at 
one  time  is  seen  a  flat,  not  very  prominent,  and  glandular-looking  thickening  of  the 
mucosa,  while  in  other  cases  there  are  produced  nodular  and  prominent  swellings. 

I  cannot  agree  with  Gottstein  that  the  infiltration  is  often 
absorbed.  The  reduction  in  swelling  which  takes  place  may- 
produce  apparent  absorption,  but  it  is  at  the  cost  of  indurating 
and  stenosing  cicatricial  contractions. 

With  the  exception  of  the  epiglottis,  which  is  the  part  most 
frequently  attacked,  the  cartilages  of  the  larynx  seldom  undergo 
inflammation  or  degeneration.  Gottstein,  however,  mentions  that 
exfoliation  of  the  arytenoid  cartilage  was  once  observed  by  Eppinger, 
and  partial  destruction  of  the  thyroid  cartilage  by  Idelson. 

It  is  of  great  interest  to  endeavour  to  trace  what  is  the  connec- 
tion between  lupus  and  tubercle.  As  has  been  already  remarked, 
there  are  an  equal  number  of  eminent  observers  arrayed  both  for 
and  against  the  view  that  the  bacillus  of  the  two  diseases  is  iden- 
tical ;  and  chnical  evidence  would  appear  to  show  that  there  is  a 

28 


434 


DISEASES  OF  THE  THROAT  AND  NOSE. 


decided  similarity  between  the  two  affections.  Neisser  is  of 
opinion  that  '  QuaHtatively  (probably)  the  bacilli  are  the  same, 
only  quantitatively  there  is  a  difference,  which  is  intensified  by  the 
less  favourable  nutritive  conditions  in  the  cooler  skin.'  But  there 
are  many  reasons  for  supposing  that  the  distinction  between  the 
two  is  not  one  simply  of  quantity  ;  for  lupus  is  very  little,  if  at  all, 
more  rapid  in  its  progress  when  it  attacks  the  mucous  membrane 
than  when  it  is  manifested  in  the  '  cooler  '  skin  ;  and,  moreover, 
from  the  vital  point  of  view,  tuberculosis  is  much  more  universally 
and  rapidly  fatal  to  life  than  lupus.  The  probable  truth,  then,  is 
that,  though  perhaps  not  morphologically  distinguishable  from 
that  of  tubercle,  the  microbe  of  lupus  is  the  less  powerfully  infec- 
tive both  locally  and  constitutionally,  or,  as  Marty  tersely  has 
it,  lupus  is  an  '  attenuated  tuberculosis.' 

Symptoms  :  A.  Functional. — Without  entering  at  length  into 
each  symptom,  generally  it  may  be  said  at  once  that  whether  in 
the  mouth,  pharynx,  or  larynx,  the  symptoms  are  slight,  out  ol 
all  proportion  to  physical  signs ;  a  fact  in  which  most  observers 
with  practical  experience  are  agreed.  In  the  only  case  narrated 
by  Gottstein,  *  the  patient  had  neither  pain  nor  discomfort  in  the 
throat,  and  was  much  astonished  on  being  told  that  her  throat 
was  affected  by  the  same  disease  as  her  ear'  (the  primary  scat 
of  the  lupus).  A  similarly  entire  unconsciousness  of  serious 
laryngeal  mischief  was  exhibited  by  Orwin's  patient.  In  three 
cases  mentioned  by  Homolle,  two  had  no  knowledge  of  any 
trouble  antecedent  to  cicatrization.  In  the  cases  of  Asch.  and 
Lefferts,  however,  there  was  considerable  dysphagia,  and  dis- 
tressing cough  with  hoarseness  and  a  sense  of  obstruction  or 
tumefaction  in  the  throat. 

B.  Physical. — I  have  seen  only  one  case  in  which  lupous 
ulceration  was  exhibited  in  the  mouth,  apart  from  those  alluded 
to  Vv'here  the  gums  were  attached. 

Case  3. — W.  B.,  aged  43,  a  waiter,  presented  himself  at  the  Throat  and  Ear 
Hospital  in  April,  188 1,  on  account  of  ulceration 
at  the  angle  of  the  right  lip,  which  was  of  true 
lupous  character,  and  extended  inside  the  cheek. 
On  the  right  arch  of  the  palate  and  involving  the 
uvula  was  a  group  of  highly  inflamed  molluscus- 
like  nodules  (Fig.  CXLVIII.).  The  larynx  was 
healthy.  There  was  a  large  cicatrix  on  the  right  side 
of  the  neck,  of  which  he  could  give  no  history,  CXLyill.  —  Lupus  of  the 

.      .  .1,      1  J  u  .1,         1  •  t.  ^o^T  Palate. 

except  that  there  had  been  a  sore  there,  which 

healed  before  he  was  eight  years  old.  He  complained  of  no  symptom  but  the  disfigure- 
ment  of  his  lip. 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  435 


In  the  palate  I  have  seen  several  cases.  As  the  early  manifes- 
tations of  lupus  in  this  region  have  not,  I  believe,  been  described, 
I  shall  give  my  impressions  at  length.  In  only  one  has  the 
deposit  been  of  such  a  nodulated  character  as  in  the  one  just 
described.  In  all  the  portion  of  mucous  membrane  implicated  is 
somevv^hat  congested,  the  hypersemia  being  more  limited  than  in 
ordinary  pharyngitis  ;  where  there  is  ulceration,  the  areola  is  much 
less  vivid  than  in  syphilis,  but  distinctly  more  so  than  in  tubercu- 
losis, and  with  an  absence  of  the  general  anasmia  of  the  surface, 
characteristic  of  the  last-named  lesion.  The  ulceration  is  neither 
so  generally  granular  nor  so  superficial  as  in  phthisis.  It  is  dis- 
tinctly more  torpid  than  in  either  this  disease  or  syphilis.  Ulcera- 
tion of  the  velum  does  not  appear  to  proceed  from  the  nasal 
surface  of  the  palate,  as  is  the  rule  in  tertiary  syphihs,  but  from  the 
buccal ;  and  though  in  one  case  I  could  pass  a  probe  an  eighth  of 
an  inch  or  more,  there  was  no  perforation.  When  destruction  of 
tissue  takes  place  it  is  not  as  a  defined  hole,  but  as  a  widening 
gap.  I  have  seen  but  one  case  with  inflammatory  nodulation  and 
acute  ulcerating  ravages  to  anything  like  the  extent  described  by 
other  observers,  and  that  was  m  a  child  exhibited  at  the  Medical 
Society  by  Dr.  Colcott  Fox,  in  November,  1886.  This  patient's 
throat  very  much  resembled  that  depicted  in  Fig.  113,  Plate 
XIII.,  only  that  it  was  more  actively  inflamed. 

The  appearance  of  the  uvula  is  peculiar.  It  is  not  inflamed 
and  oedematous  as  in  syphilis,  nor  anaemic  and  shrunken  as  in 
tuberculosis,  but  it  is  often  swollen  as  with  solid  infiltration,  so 
as  to  give  a  club-shaped  appearance ;  it  is  generally  distinctly 
congested,  and  frequently  nodulated. 

The  first  case  in  which  I  noticed  this  appearance  occurred 
in  my  hospital  practice  seven  years  ago,  and  is  herewith  re- 
lated from  the  notes  of  Dr.  Dundas  Grant,  who  was  then 
Registrar : 

Case  4. — Ann  D.,  aged  46,  married  six  years,  applied  as  an  out-patient — not  on  account 
of  her  throat,  but  for  otalgia  on  the  right  side — at  the  Central  Throat  and  Ear  Hospital,  on 
the  15th  of  April,  1880.  Observing  a  large  (healed)  lupoid  cicatrix  on  the  upper  lip,  it  was 
ascertained  that  she  had  been  the  subject  of  tubercular  lupus  (non-exedens)  of  the  nose, 
and  then  of  the  cheeks,  since  childhood.  The  health  had  always  been  excellent  till  the 
attack  of  ear-ache,  which  had  commenced  a  fortnight  back.  She  had  had  one  child,  who 
had  died  of  bronchitis  at  six  months.  A  doctor  had  noticed  that  her  throat  was  affected 
sixteen  years  previously,  but  it  had  really  never  troubled  her.  There  was  absolutely  no 
symptom  of  voz'ce,  artiadation,  or  deglutition  of  an  abnormal  character,  but  she  stated 
that  her  breath  had  always  been  rather  .short  on  exertion  or  during  conversation.  On 
examination  of  her  throat  it  was  observed  that  at  the  tip  of  the  uvula  was  a  sessile 
*  tuberculated  '  growth  of  red  colour,  and  on  the  soft  palate  two  raised  red  patches,  and 


4i6 


DISEASES  OF  THE  THROAT  AND  NOSE. 


several  more  or  less  visible  spots  much  resembling  ihe  characteristic  'apple-jelly'  appear- 
ance of  lupus  on  the  skin.  The  left  posterior  pillar  was  adherent  to  the  pharynx,  to 
which  it  was  bound  down  by  a  dense,  white,  stellate  cicatrix.  The  larynx  was  normal, 
except  the  epiglottis,  the  right  half  of  which  was  much  swollen  and  irregular,  with  small 


Fig.  CXLIX.— Palatal 
Appearance. 


Fig.  CL.— Laryngoscopic 
Appearance. 


nodular  elevations  over  the  swollen  part ;  the  left  half  was  slightly  thicker  than  normal, 
and  had  one  or  two  nodules  on  its  superior  surface. 

It  may  be  added  that  the  otalgia  was  found  to  be  unconnected  with  the  lupus,  and  was 
of  a  simple  character. 

The  following  are  brief  notes  of  the  palatal  and  laryngeal  cases 
I  saw  at  St.  John's  Hospital  in  the  summer  of  1886.  I  pointed 
out  the  morbid  appearances  to  either  Dr.  Harries  or  Dr.  Campbell 
at  the  time,  and  some  of  them  were  later  verified  by  the  examina- 
tion of  my  colleagues,  and  by  visitors  on  the  occasion  of  a  lecture 
I  gave  on  the  subject  at  the  Central  Throat  and  Ear  Hospital. 
It  is  interesting  to  note  that  in  every  one  there  was  lupus  of  some 
portion  of  the  face  ;  and  to  this  experience  in  the  eleven  cases  I 
have  seen,  No.  2  is  the  only  exception. 

Case  5. — E.  G.,  a  single  girl,  aged  20,  had  suffered  from  lupus  for  ten  years.    It  had 

commenced  at  the  lower  border  of  the  mastoid, 
whence  it  extended  to  the  angle  of  the  jaw.  The 
^  uvula  was  distinctly  clubbed,  red,  and  nodulated 
(Fig.  CLI.),  and  the  fauces  generally  congested. 
The  epiglottis  was  of  a  red  colour,  but  the  outline 
of  its  free  border  was  sharp,  and  the  valve  free 
from  thickening.  The  condition  of  the  uvula 
strongly  resembled  that  described  in  Gottstein's 
case. 

Case  6. — E.  W.,  a  female  patient,  aged  17  ; 
pareuis  and  iamiiy  healthy.  She  had  a  cicatrix  of  lupus  on  her  neck  ;  her  face  was  hideously 
disfigured  by  ulceration,  which  had  commenced  at  the  right 
angle  of  the  nose,  and  had  extended  to  cheek  and  lips,  so 
that  her  mouth  was  dreadfully  contracted.  It  was  not  pos- 
sible to  see  her  larynx  well.  What  I  did  see  appeared 
healthy,  but  the  uvula  was  red,  granular,  and  clubbed  ;  on 
its  surface  as  well  as  just  above  it  on  the  velum  was  a 
shallow  ulcer,  with  raised  edge  (Fig.  CLIL).    The  patient 

Fig.  CLII   E  \rly  Lupus  ^^^^  riever  experienced  the  least  pain  in  swallowing.  The 

CF  THE  Uvula  and  voice  was  somewhat  hoarse,  but  the  change  had  been  be- 
"Velum.  lieved  to  be  entirely  due  to  the  effects  of  the  disease  in  her 

nose  nnd  mouth. 


Fig.  CLI. — Early  Lupous  Infil 
tration  of  Uvula. 


LUPUS  OF  THE 


MOUTH,  PHARYNX,  AND 


LARYNX. 


437 


In  another  case  (No.  7),  that  of  E.  D.,  a  female  child,  aged  8,  there  was  a  similar 
affection  of  the  uvula  (Fig.  CLIII.),  not  so  far 
advanced,  and  a  small  shallow  ulcer  on  the  superior 
surface  of  the  left  anterior  pillar. 

The  historical  notes  of  the  follow- 
ing two  cases  are  given  in  Dr.  Camp-  t 

bell's  own  words  from  his  pamphlet :  fig.  CLIIL— Early  Lupous  Ul- 
ceration OF  Left  Anterior 
Case  8. — 'James  V,,  set.  24;  father  phthisical,     Faucial  Pillar. 
mother  healthy,  also  a  brother  and  sister  ;  some 

others  died  in  infancy ;  cause  unknown.  Fifteen  years  ago  had  a  dloza  on  the  nose,  followed 
by  ulceration,  and  shortly  after  again  bruised  his  face  by  a  fall.  Ulceration  spread  over  the 
whole  face,  except  the  forehead,  destroying  cartilages  and  septum  of  nose,  attacking  both 
pinnse,  and  spreading  downwards  and  backwards  towards  the  back  of  the  neck.  Two 
similar  patches  of  ulceration  afterwards  appeared  on  inner  surface  of  left  thigh,  one  on 
anterior  surface  of  right  forearm,  and  one  on  inner  surface  of  left  upper  arm.  Six  months 
ago  an  iron  bar  fell  on  second  toe  of  right  foot,  which  soon  after  developed  similar  ulcera- 
tion. There  is  also  a  patch  on  ulnar  aspect  of  right  wrist.  May  17,  1886:  All  these 
lesions  exhibit  the  typical  characters  of  lupus.  The  teeth  in  both  jaws  are  crowded,  and 
the  gums  swollen  and  ulcerating.  Mr.  Lennox  Browne  diagnosed  lupus  of  larynx  and 
uvula.' 

The  ulcerations  of  the  uvula  in  this  case  were  deeper  than  in  any  of  the  others,  and 
had  decidedly  raised  margins  (Fig.  CLIV.).    As  to  the  larynx  (Fig.  CLV.)^  the  epiglottis 


Fig.  CLIV.— Lupus  of  Uvula  and 
Soft  Palate. 


Fig.  CLV. — Lupus  of  the 
Larynx. 


was  very  pale  and  thickened,  and  at  its  right  inferior  margin  there  was  slight  worm- 
eaten  ulceration,  which  showed  some  signs  of  cicatrization.  The  inter-arytenoid  fold  was 
thickened  ;  the  cords  somewhat  congested. 

Case  9. — '  A.  P.,  aet.  23  ;  male  ;  good  family  history.  Disease  began  on  the  upper  lip 
six  years  ago,  and  spread  slowly.  Was  treated  with  the  usual  remedies.  March  22, 1886  : 
Nasal  cartilages  gone,  and  nostrils  contracted ;  upper  lip  red,  brawny,  thickened  ;  the 
nodules  confluent  and  ill-defined  ;  a  solitary  discrete,  typical  nodule  on  right  cheek,  near 
the  nose.  On  the  inner  aspect  of  the  right  forearm  there  is  a  rounded  purplish-red  patch, 
with  edges  slightly  raised  and  nodulated.  Some  cicatrization  in  centre  of  patch,  which 
has,  however,  never  ulcerated.  June  8  :  Lupus  of  the  larynx  was  diagnosed  by  Mr. 
Lennox  Browne  on  this  date.' 

I  did  not  make  a  drawing  of  this  case  because  the  laryngeal 
appearance  so  closely  resembled  that  in  the 
foregoing,  and  also  in  the  next  : 

Case  10. — Louisa  F.,  aged  16,  had  suffered  from  lupus  of 
the  nose  for  five  years.    Her  teeth  were  characteristically 

crowded.    Lupoid  manifestations  were  absent  in  the  pharynx  Yig    C\  vt 

and  fauces,  but  the  epiglottis  was  pale,  with  nodulated  n\G    of  '"eJiglotits 

and  solid-looking  thickening  (Fig.  CLVL).  in  Lupus. 


438 


DISEASES  OF  THE  THROAT  AND  NOSE. 


In  addition  to  the  foregoing,  I  have  had  one  more  case  in  my 
own  practice  : 

Case  ii. — Eleanor  B.,  aged  19,  single,  came  under  my 
care  at  the  Central  Throat  and  Ear  Hospital  on  April  29, 
1886,  on  account  of  ulceration  of  the  nostril,  of  which 
there  had  been  visible  evidence  for  a  year  ;  but  she  had 
suffered  from  a  certain  sensation  of  discomfort  in  the 
anterior  nasal  pasage  for  a  period  fully  three  times  as 
long.    She  was  the  youngest  of  six,  all  of  whom  were 
well  and  strong,  and  she  herself  had  always  enjoyed 
Fig.  CLVII. — Inflamma  j  ory  good  health.    Her  father  was  alive,  aged  67,  and  her 
Thickening  and  Nodula-  j^^.^ther  had  died  at  48  of  an  abdominal  'tumour.' 
TioN    OF    Epiglottis    in  t  ,      ^.  .  1    i   .     •  , 

j^ypyg  Lupous  ulceration  was  seen  to  be  destroymg  the  cartilage 

of  the  left  nostril,  and  was  confined  to  that  spot.  The 
palate  was  normal  in  foirm,  but  rather  congested.  In  the  larynx  (Fig.  CLVH.),  the 
epiglottis,  which  was  very  pendulous,  was  seen  to  be  distinctly  thickened,  hyperasmic  and 
flesh-like  in  texture,  and  both  its  free  edge  and  superior  surface  were  somewhat  nodulated  ; 
the  vocal  cords  and  the  rest  of  the  larynx  were  normal.  There  was  not  the  least  dis- 
comfort experienced  in  the  performance  of  any  function  of  the  throat. 

I  have  recently  seen  this  patient  again  (April  2,  1887).  The  ulceration  of  the  nostril  has 
healed  under  treatment  by  scraping  and  cautery.    The  laryngeal  condition  is  unchanged. 

In  three  cases  (Nos.  2,  5,  and  11)  there  was  marked  inflam- 
matory redness  of  the  laryngeal  mucosa  ;  in  others  there  was 
slight  congestion.  Although  in  each  that  has  presented  laryngeal 
signs  the  epiglottis  has  been  thickened,  in  only  three  (Nos.  2,  4, 
and  11)  has  there  been  nodulation  ;  in  none  was  this  last-named 
lesion  seen  to  the  excessive  extent  pictured  in  text-books ;  and  I 
cannot  but  think  that  observers  have  been  too  ready  to  see  this 
nodular  condition,  as  first  figured  by  "^Tiirck,  or  have  ignored  as 
lupous  the  more  ordinary  though  less  marked  appearances 
delineated  in  the  foregoing  sketches.  Ramon  de  la  Sota,  of 
Seville,  as  he  has  seen  the  disease,  finds  that  there  is  always  active 
hyperaemia,  and  distinguishes  the  lupous  tubercle  by  its  very  red 
colour  from  the  leprous  tubercle,  which  is  opaque,  and  of  a  turbid 
white.  It  is  possible  that  the  habitual  use  of  tobacco  among  his 
patients  may  account  for  the  constancy  of  the  congestion.  He 
also  considers  that  lepra  is  characterized  by  a  greater  degree  of 
anaesthesia.  I  have  never  seen  a  case  of  laryngeal  lepra,  but 
diminished  sensibility  is  a  marked  symptom  of  lupus. 

Differential  Diagnosis. — The  laryngeal  diseases  with  which 
lupus  is  likely  to  be  mistaken  are  syphilis  and  tuberculosis.  While 
Gottstein  considers  confusion  of  lupus  with  the  former  the  more 
excusable,  Lefferts  is  of  opinion  that  the  demarcation  between  the 
two  is  distinct.  This  may  be  granted  wherever  there  is  concur- 
rent lupus  of  the  skin ;  but  there  Is  the  superadded  difficulty 
that  some  observers  will  not  admit  that  necrosis  of  bone  is  a 
crucial  test  between  the  two.    This,  however,  is  the  guide  in  my 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  439 


own  practice,  and  for  it  I  have  the  support  of  Mr.  Jonathan 
Hutchinson.  The  fact  that  a  patient  has  brothers  and  sisters, 
both  older  and  younger,  free  from  any  taint,  is  of  really  minor 
importance  and  I  am  entirely  in  accord  with  Neisser,  who  says 
that  *  the  history,  as  a  rule,  is  comparatively  worthless,  whether  it 
points  to  syphilis  or  not.  In  the  former  case,  because  lupus  co- 
existing with  syphilis  presents  no  striking  features  ;  in  the  latter, 
because  ulcerous  syphilis  often  develops  so  many  years  after 
infection  that  the  credibility  of  anamnestic  data,  in  case  syphiHs 
is  denied,  is  very  slight.'  It  is  far  more  important  to  remember, 
as  the  same  author  has  stated,  that  while  *  lupus  has  nothing  in 
common  with  syphilis  in  any  direction,  both  diseases  may  run 
side  by  side  in  the  same  individual.'  The  effects  of  treatment  are 
of  much  greater  assistance.  In  lupus,  mercurial  treatment  always 
aggravates  both  the  subjective  and  objective  conditions,  and  an 
interesting  example  of  this  fact  is  recorded  by  Ramon  de  la  Sota. 
Improvement,  therefore,  of  the  condition,  under  long-continued 
medication  by  mercury,  must  inevitably  confirm  our  suspicion  of 
a  syphilitic  origin,  or,  at  least,  of  the  co-existence  of  a  syphilitic 
taint. 

The  laryngoscopic  appearances  of  lupus  are  far  more  allied  to 
those  of  tubercle,  but  the  comparative  slowness  of  the  pathological 
process,  the  absence  of  pain,  cough,  and  emaciation  in  the  former, 
and,  above  all,  its  disposition  to  undergo  repair  in  one  part  concur- 
rently with  extension  in  another  direction,  should  not  make  diag- 
nosis difficult.  ^^Hunt  well  puts  it  that  '  there  are  two  general 
conditions  of  the  mucous  membranes  of  the  larynx  and  pharynx 
which  strike  one  in  the  majority  of  cases,  ancBmia  and  ancesthesia 
the  former  distinguishes  it  from  syphilis,  the  latter  from  tuber- 
culosis. The  cases  of  lupus  in  which  there  is  pain  are  as  rare  as 
those  of  tubercle  in  which  there  is  none.  A  strong  point  of  differ- 
entiation from  both  syphilis  and  tuberculosis  is  the  fact  that  lupus 
of  the  larynx  is  almost  always  supra-glottic,  and  that  the  vocal  cords 
generally  escape.  All  these  points  will  indicate  that  although  there 
may  be  certain  morphological  resemblances  between  lupus  and 
tuberculosis,  the  clinical  characteristics  of  the  two  maladies  are 
thoroughly  distinctive. 

One  more  point ;  stenoses  in  lupus  are  due  to  a  general  matting 
together  of  the  inflamed  tissues,  as  shown  in  Fig.  CXLVII., 
p.  429,  and  are  very  different  from  what  is  observed  in  syphilis 
or  in  laryngeal  manifestations  of  rhino-scleroma.  It  is  hardly 
necessary  to  go  into  detail  as  to  the  points  of  differentiation  from 
carcinoma,  and  I  am  unable  from  personal  experience  to  speak  of 
lepra. 


440 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Prognosis,  Course,  and  Duration. — The  forecast  of  lupus  of 
the  throat  may  be  generally  considered  as  favourable  from  the 
vital  point  of  view,  though  when  the  larynx  is  attacked  some 
danger  is  to  be  apprehended  at  a  later  stage  from  cicatricial  nar- 
rowings  of  a  most  unyielding  character.  The  peril  is  all  the 
greater  because  interference  with  these  scars  by  incisions  is  not 
unlikely  to  lead  to  recrudescence  of  the  ulceration.  The  course 
of  lupus  is  always  slow,  and  while  it  may  possibly,  in  a  few 
cases  —  not  so  few,  perhaps,  as  was  formerly  believed — ter- 
minate in  general  phthisis  (?  pulmonary  luposis),  it  more 
often  undergoes  a  spontaneous  process  of  cure  by  evolution. 
It  is  impossible  to  make  an}^  prognostications  of  value  as  to  the 
duration  of  active  disease  ;  and  in  many  cases,  even  when  ulcera- 
tion is  arrested,  there  is  lifelong  discomfort  in  speech  and 
respiration. 

Treatment  ma)^  be  divided  into  :  i.  Abscission  and  scraping; 
2.  Cautery,  galvanic  or  actual ;  3.  Chemical  caustics  and  germi- 
cides ;  4.  Constitutional  remedies  of  the  analeptic  type. 

Abscission  of  a  uvula  when  attacked  by  lupus  is  a  sound  proce- 
dure, and  when  efficiently  performed  the  good  effects  of  scraping 
are  quite  as  marked  in  lupus  of  a  mucous  as  of  a  cutaneous  sur- 
face ;  but  it  must  be  thorough,  and  the  slightest  nodule  or  spot 
must  be  carefully  eradicated.  Either  of  these  measures  may  be 
performed  by  the  galvano-cautery,  which  affords  in  this  disease,  as 
in  all  others  of  the  throat  and  nose,  much  better  results  than  any 
form  of  actual  cautery,  for  it  is  at  once  safer  and  more  convenient 
of  employment.  After  scraping  with  an  ordinary  raspatory,  chemical 
caustics  may  often  be  usefully  applied :  the  best  is  the  perchloride 
of  mercury,  i  to  500 — either  in  powder  or  paste.  Of  germicides, 
Ramon  de  la  Sota  speaks  highly  of  lactic  acid,  and  from  my 
experience  of  that  remedy  in  faucial  diphtheria  and  tuberculosis, 
I  should  certainly  expect  it  to  be  of  good  effect  in.  this  disease  also. 
I  have  not  found  applications  of  iodine,  iodoform,  or  of  mineral 
astringents  of  the  least  use  in  lupus  of  the  throat.  Tracheotomy, 
for  the  reason  that  glottic  stenosis  is  a  rare  compHcation,  is  not 
often  necessary,  but  in  the  few  cases  in  which  it  has  been  per- 
formed the  operation  is  reported  to  have  always  had  a  favourable 
influence  on  the  progress  of  the  disease. 

A  FEW  words  remain  to  be  said  regarding  a  form  of  pharyngeal 
and  laryngeal  disease,  in  which  a  syphilitic  manifestation  occurs 
in  a  person  of  scrofulous,  strumous,  or  lupous  diathesis.  As  to 
etiology,  we  have  nothing  to  add  to  what  has  been  said  in  regard 
to  so-called  scrofulous  ulceration  of  the  pharynx  at  pp.  212,  213, 
and  to  repeat  that  while  the  diagnosis  of  faucial,  pharyngeal,  or 
laryngeal  lupus,  if  unaccompanied  by  a  previous  or  concurrent 
cutaneous  manifestation,  is  to  be  considered  dubious,  the  existence 


LUPUS  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  441 


of  necrosis  of  bone  should  in  our  judgment  at  once  point  to  the 
probabihty  of  the  case  being  primarily  syphilitic. 

Two  instances  are  appended  as  types  of  lesions  that  are 
often  ignorantly  called  lupoid  or  lupoid  syphilis  :  they  are  inserted  in 
this  situation  solely  to  enforce  the  question  of  diagnosis.  The  first 
is  an  illustration  of  a  laryngeal  affection  which,  occurring  in  a 
patient  phthisically  inchned,  strongly  resembled  lupus,  but  without 
cutaneous  corroboration,  and  with  therapeutic  evidence  of  syphiKs. 
The  second  is  one  of  cutaneous  disease  of  the  character  of  lupus, 
but  with  ulceration  of  the  palate  and  with  laryngoscopic  signs 
which  clearly  establish  it  to  be  also  syphilitic. 

Case  12. — Elizabeth  C,  aged  26,  married  eight  years,  and  with  one  child  5  months  old, 
came  under  my  care  at  the  Central  Throat  and  Ear  Hospital  in  March  8,  1886,  com- 
plaining of  soreness  of  the  throat  and  loss  of  voice,  which  had  existed  for  seven  weeks, 
and  was  believed  to  be  due  to  cold.  Her  voice  was  reduced  to  a  whisper.  There  was  a 
slight  dry  cozigh  ;  rather  worse  at  night.  She  said  that  her  breathing  was  short  at  times, 
but  deglutition  was  easy  and  normal.  The  pain  was  described  as  a  smarting,  with 
dryness  on  the  larynx.  Her  tonsils  were  rather  enlarged,  especially  the  right ;  the  back 
of  the  pharynx  was  granular.  Beyond  the  graphic  note  of  alteration  in  the  configuration 
of  her  larynx  as  rendered  in  facsimile  on  Fig.  CLVHL,  no  remark  was  made  on  her  case- 


Fig.  CI.VHT.— Laryngral  AprEAiiANCE, 
March  8,  1886, 


Fig.  CLVHI.*-The  same. 


ome 
She 


paper  as  to  laryngeal  change  beyond  'slight  congestion.'    On  auscultation, 
dulness  was  noticed  at  the  front  of  left  apex,  but  no  rales,  and  good  inspiration, 
was  ordered  hypophosphites  and  cod-liver  oil  ;  she  only  attended  for  three  weeks. 

On  February  18,  1887,  this  patient  returned  and  came  under  the  care  of  my  colleague, 
Mr.  Jakins.  She  stated  that  she  had  got  much  better  by  previous  treatment,  but  that  for 
the  last  five  months  her  sore  throat  had  returned,  her  breathing  was  more  difficult,  her 
taste  was  impaired,  but  there  was  no  pain  whatever.  Her  tongue  was  seen  to  be  glazed, 
deeply  cracked  and  superficially  ulcerated.  Her  uvula  was  swollen  and  thickened,  and 
It,  as  well  as  the  solt  palate  and  anterior  pillars, 
were  thrown  into  thick  folds  with  deep  rugce 
between  (Fig.  CLIX.).  The  back  wall  of  the 
pharynx  was  still  somewhat  granular.  The  nodu- 
lated and  thickened  condition  of  the  larynx  pre- 
viously noted  had  decidedly  increased,  as  may  be 
seen  by  comparison  of  the  laryngoscopic  figure 
(CLVni.*)  with  that  first  delineated,  and  almost 
exactly  simulated  that  of  true  lupus.  The  lungs 
(repeatedly  examined,  and  by  various  members  of 
the  staff)  appeared  quite  healthy,  both  on  percus- 
sion and  auscultation.  In  consultation  with  Mr. 
Jakins,  I  expressed  an  opinion  that  the  case  was  ^■'^^^ 
now  undoubtedly  syphilitic,  and   the  result  of 


-Faucial  Appearance, 
February  18,  1SS7. 


DISEASES  OF  THE  THROAT  AND  NOSE, 


treatment  by  biniodide  of  mercury,  combined  with  cod-liver  oil  and  antisepic  oro-na^al 
inhalations,  soon  confirmed  the  diagnosis. 

It  is  to  be  noted  that  in  this  case  there  is  no  manifestion  on  the 
skin,  but  there  is  existence  of  a  condition  of  the  tongue  more  aUied 
to  syphiHs  than  to  lupus,  and  a  sister  is  in  that  respect  similarly 
affected.  There  is  also  doubtful  evidence  of  incipient  tuberculosis. 
In  both  this  and  the  following,  the  syphilitic  dyscrasia  was  probably 
congenital  or  inherited,  though  sterility  for  the  first  seven  years  of 
married  Hfe  in  the  first  case  is  capable  of  other  interpretation. 

Case  13. — ^Jane  S.,  aged  20,  single,  attended  the  Central  Throat  and  Ear  Hospital  as  ar 
cut-patient  in  November,  1885,  and  again  in  February,  1887.  The  following  history  was 
obtained  at  the  time  of  her  second  attendance  :  She  thinks  she  had  always  been  '  ill ' 
from  birth  and  in  early  life,  but  remembers  that  she  was  quite  well  at  7.  When  12  years 
old  was  bitten  on  the  nose  at  the  inner  canthus  of  the  right  eyelid  by  a  gnat  ;  remembers, 
Jiowever,  that  there  was  a  scar  on  the  nose  before  this,  but  never  a  sore.  [There  are  also 
several  depressed  circular  scars  on  the  thighs  and  calves,  of  the  origin  of  which  she  has  no 
recollection.]  After  the  bite  she  had  an  abscess  of  the  nose,  and  about  this  time  her  moutli 
became  bad  ;  an  ulcer  formed  in  the  palate  and  proceeded  to  perforation.  She  was  treated 
at  various  hospitals  and  convalescent  homes  on  and  off  for  two  years,  and  her  nose  nearly 
healed,  but  the  right  eyelid  discharged  and  was  drawn  down  by  cicatricial  fluid  contraction  ; 
i'c  remained  llius  until  November,  1885,  when  she  lost  her  voice  without  pain  or  soreness. 

This  improved  under  treatment  here,  but  has  never 
been  completely  recovered.  Soon  after  this  time 
the  nose  became  again  affected,  and  spread  from 
the  right  inner  canthus  downwards  to  the  cheek, 
and  the  patient  was  admitted  to  Middlesex  Hos- 
pitul  under  Mr.  Lawson.  At  that  time  the  eyelid, 
although  drawn  down,  was  not  ulcerated.  After 
a  stay  of  three  or  four  weeks  she  left,  with  the 
patch  on  the  nose  and  cheek  (/tn^e  healed. 

During  the  last  month  the  disease  has  spread  to 
the  inner  half  of  both  upper  and  lower  lids.  It  involves  the  angle  between  the  canthus 
and  nose,  also  the  bridge  of  the  nose,  and  creeps  superficially  down  the  right  side  of  the 
nose  to  the  cheek,  and  it  has  now  for  the  first  time  involved  the  ala  of  the  right  nostril, 
a  portion  of  which  is  destroyed. 

There  is  a  central  perforation  of  the  hard  palate  of  the  size  of  an  ordinary  lead-pencil, 
jagged  eroded  ulcers  along  the  central  raphe  of  the  soft  palate,  and  adhesion  of  the  uvula 
to  the  right  faucial  pillar.  With  the  laiyngoscopc  (Fig.  CLX.)  the  epiglottis  is  seen  to 
l)e  red  and  thickened,  and  with  a  slight  fissure  in  the  centre  ;  there  is  no  active  ulcera- 
tion, but  concurrently  with  the  inflammatory  thickening  the  free  edge  is  notably  white  and 
nodulated.  With  the  exception  that  the  epiglottis  is  inflamed,  the  appearance  of  the 
free  edge  strikingly  resembles  the  coloured  illustrations  of  syphilis  in  Figs.  61  and  67, 
Plate  VII.,  at  the  end  of  this  book.  The  vocal  cords  are  of  a  dirty  reddish-grey  colour, 
and,  so  to  speak,  degenerated  in  substance,  but  so  far  as  can  be  seen  are  not  ulcerated. 

The  teeth  are  irregularly  shaped,  small,  and  pegged  in  the  upper  jaw  :  more  regular  in 
the  lower.  Nothing  abnormal  in  the  optic  discs  can  be  discovered  with  the  ophthalmo- 
scope.   The  family  history  is  apparently  good. 

In  the  second  case  the  appearances  of  the  face,  eyelid,  and 
larynx  strongly  resemble  those  of  lupus ;  but  necrosis  of  the  hard 
palate,  and  certain  other  commemorative  points,  clearly  establish 

syphilitic  origin  of  the  malady.    The  history  of  the  gnat-bite 


LEPROSY  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  443 


would  point  to  traumatism  as  the  exciting  factor  of  the  ulceration, 
and  might  encourage  a  thought  that  the  truly  lupous  nature  of 
the  disease  was  established  ;  but  the  pre-existence  of  a  scar  renders 
such  an  hypothesis  untenable.  I  lately  (1887)  saw  a  very  similar 
case  in  consultation  with  Dr.  Campbell.  There  was  a  succinct 
history  of  a  blow  on  the  nose  from  a  stone  as  the  first  cause  of  a 
nasal  disease  which  had  destroyed  both  bone  and  cartilage,  but  on 
cross-examination  there  was  clearly  pre-existence  of  inherited 
syphilitic  lesions.  There  is,  of  course,  equal  probability  that 
traumatism  may  excite  to  active  disease  in  the  syphilitic  as  in  the 
lupous  dyscrasia. 

LEPROSY. 

Leprosy  of  the  pharynx  and  upper  air-passages  is  limited  to  the 
so-called  tubercular  form  of  leprosy :  that  which  attacks  the  skin, 
and  is  especially  manifested  in  those  patients  in  whom  the  face  is 
so  affected.  Its  appearance  in  the  throat,  nearly  every  part  of 
which  may  be  attacked,  is  a  comparatively  late  occurrence.  The 
interest  of  the  disease  is,  in  the  present  stage  of  science,  of  purely 
clinical  interest ;  for  not  only  is  no  treatment  of  any  avail,  but, 
as  stated  at  page  222,  the  disease  is  secondary  to  cutaneous 
evidences,  and  this  both  in  the  date  of  its  invasion  and  in  its 
importance  to  the  well-being  of  the  patient. 

The  manifestation  of  a  primary  leprosy  in  the  throat  is  indeed 
even  more  doubtful  than  that  of  lupus. 

It  may  be  useful,  as  the  result  of  my  visit  to  the  Leper  Estab- 
lishment in  Robben  Island,  South  Africa,  and  in  consideration 
of  the  greater  attention  recently  given  to  the  subject,  to  state 
concisely  the  appearances  as  I  have  observed  them,  and  as  are 
remarked  by  other  standard  authors. 

Symptoms,  Subjective. — The  voice  is,  as  in  lupus,  the  earliest 
indication"  of  leprous  invasion,  and  is  of  very  much  the  same 
character.  It  may  be  described  as  commencing  with  ordinary 
hoarseness  and  the  so-called  nasal  timbre  ;  it  is  sometimes  charac- 
terized as  shrill,  but  is,  I  am  informed,  and  as  I  observed  in  the 
cases  I  saw,  more  often  distinguished  by  an  actual  though 
gradual  diminution  in  pitch,  to  be  later  followed  by  even  complete 
suppression. 

Another  similitude  to  lupus  is  that  there  is  but  seldom  mogi- 
phonia,  pain  in  speaking ;  dysphagia,  difficulty,  or  odynphagia, 
pain,  in  swallowing,  or,  indeed,  inconvenience  in  any  functional  exer- 
cise of  the  throat.  I  saw  one  case  at  Robben  Island  in  which  there 
was  extensive  and  deep  ulceration  of  both  the  hard  and  soft  palate, 


■444 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  whole  surface  of  the  tongue  to  its  root,  and  of  all  the  visible 
pharynx,  with  destruction  of  the  uvula,  but  in  which  there  was  abso- 
lutely no  complaint  of  pain,  and  I  remark  that  in  ^^Morell  Mackenzie's 
able  essay,  out  of  twenty-five  cases  tabulated,  dysphagia  was  only 
present  in  one.  This  author  j  ustly  observes  that '  it  is  wonderful  how 
slight  the  pain  often  is,  even  in  cases  where  the  whole  mouth, 
tongue,  and  fauces,  as  well  as  pharynx,  are  extensively  involved.' 
Mackenzie  doubts  occurrence  of  leprous  complications  in  the  throat 
*in  the  purely  anaesthetic  form  of  the  disease,'  but  surface  anaes- 
thesia appears  to  be  the  characteristic  of  all  forms  of  leprosy,  and  is 
decidedly  distinctive  of  its  presence  in  the  regions  now  under  con- 
sideration. With  regard  to  dyspnoea,  the  same  may  be  said  as  to 
absence  of  urgency,  for  cases  have  been  reported  in  which  respira- 
tion was  unaffected,  even  though  the  calibre  of  the  glottis  was  so 
narrowed  as  to  hardly  admit  a  straw.  Tracheotomy  is  indeed 
but  seldom  indicated,  and  I  did  not  find  a  single  recorded  case  in 
which  the  operation  had  been  performed  at  the  Cape  establish- 
ment. Death  by  oedema  of  the  glottis  is,  however,  said  to  be  not 
uncommon.  The  sense  of  smell  is  often  impaired  or  altogether 
lost  when  the  nose  is  extensively  invaded,  which  is  not  infre- 
quently the  case  ;  but  taste,  though  somewhat  deadened  where 
perception  of  odour  is  lost,  is  seldom  entirely  abrogated. 

The  Objective  signs  of  leprosy  in  the  pharynx,  in  its  early 
stages,  are  difficult  to  diagnose  from  those  of  lupus.  They  are 
hyperaemia  followed  by  papillations  which  increase  in  size,  and  by 
indurations  which  become,  later,  fissured  and  ulcerated.  This  con- 
dition generally  commences  in  the  uvula,  as  does  lupus,  and  then 
extends  to  the  whole  palate,  soft  and  hard,  and  lastly  to  the  base 
of  the  tongue  (hngual  tonsil).  Some  cases  I  saw  of  leprosy  in  the 
tongue — other  corroborative  evidence  being  unconsidered — would 
be  easily  mistaken  for  tertiary  syphilis.  Loss  of  tissue  is  decidedly 
more  common  in  lepra  than  in  lupus,  but  perhaps  the  most  distinc- 
tive feature  between  the  diseases  is  '  the  pale,  yellow,  thickened, 
glazed  look  that  characterizes  the  whole  of  the  mucous  membrane 
of  the  mouth  and  throat,  an  appearance  which  might  almost  suggest 
that  all  the  parts  had  been  infiltrated  with  tallow  '  (Mackenzie). 
23Hillis,  of  Demerara,  finds  this  '  pale  pallid  bloodless  condition 
consecutive  to  the  earher  and  very  transitory  stage  of  congestion, 
at  a  very  early  stage  of  every  case  of  tuberculated  leprosy  which 
affects  the  throat,  and  he  likens  it  to  that  of  a  person  suffering 
from  pernicious  anaemia,  though  the  patient  may  not  be  suffering 
from  this  disease  or  be  otherwise  bloodless.  I  have  seen  a  modified 
appearance  of  this  nature  in  advanced  cases  of  lupus. 


LEPROSY  OF  THE  MOUTH,  PHARYNX,  AND  LARYNX.  445 


In  the  larynx,  it  is  very  difficult,  and  indeed  generally  impossible, 
to  say  what  is  the  condition  below  the  level  of  the  epiglottis,  for 
that  cartilage  is  always  so  enormously  thickened  by  infiltration 
(Fig.  CLX.  a)  as  to  prevent  any  movement  in  phonation  or  other- 
wise, and  so  to  constitute  an  insurmount- 
able obstacle  to  further  inspection.  At 
a  later  stage  ulceration  breaks  down  the 
tissue,  and  Mackenzie  has  seen  one  case 
in  which,  the  epiglottis  being  eaten 
away,  he  was  able  to  observe  a  similar 
thickening  of  all  parts  forming  the  upper  Fig.  CLX.  a.— t.eprosy  or 
circumference  of  the   larynx— namely,  '^"^  Larynx. 

arytenoid  cartilages  with  the  ary-epiglotticand  inter-arytenoid  folds. 
The  cords  also  were  infiltrated  and  ulcerated.  I  have  not  been  so 
fortunate  as  to  obtain  such  a  view,  and  my  observations  have  led 
me  to  believe  that  in  leprosy,  as  in  lupus,  though  there  is  consider- 
able general  thickening  there  is  not,  as  a  rule,  a  tendency  to  separate 
tubercles  or  nodules.  Ulceration  is  comparatively  rare,  and  loss  of 
substance  appears  to  result  from  that  same  curious  process  of 
atrophic  absorption  of  the  vital  tissues,  which  is  characteristic  of 
the  disease  when  attacking  the  hands  or  feet.  In  forty  cases  tabu- 
lated by  Hillis,  the  epiglottis  was  markedly  thickened  in  eleven, 
destroyed  by  ulceration  in  one,  so  that  '  only  a  stump  '  remained ; 
but  in  only  two  instances  are  distinct  tubercles  in  this  situation 
recorded.  The  disease  may  extend  to  the  trachea  and  bronchi, 
but  respects  the  lung  tissue  and  also  the  oesophagus.  A  bacillus 
of  leprosy  has  been  discovered  by  Hansen,  which  is  not  unlike 
that  of  lupus,  and  it  is  impossible  not  to  see  that  there  is  a 
marked  family  likeness  between  these  two  diseases.  The  fre- 
quent use  of  the  word  *  tubercle '  when  describing  leprosy,  is 
somewhat  unfortunate ;  nevertheless  the  malady  has  as  near 
a  relationship  to  tuberculosis  as  has  lupus.  Granting  that 
lupus  is,  as  Marty  has  said,  an  attenuated  tuberculosis,  may  not 
leprosy  be  described  as  a  tuberculosis  still  more  attenuated,  as 
regards  its  slowness  of  progress  and  duration,  but  more  virulent 
in  its  contagiousness  and  in  the  extent  of  its  ravages,  and  this 
both  in  its  attacks  on  the  skin  and  on  the  mucous  membrane  ?  It 
is  possible  that,  at  some  not  distant  date,  varieties  of  bacillus 
may  be  found  in  the  two  varieties  of  leprosy. 

24Thin  has  well  described  the  morbid  anatomy  of  leprosy  in 
these  situation,  and  the  reader  who  is  further  interested  cannot 
do  better  than  refer  to  that  authority. 


446 


DISEASES  OF  THE  THROAT  AND  NOSE, 


REFERENCES  TO  AUTHORITIES. 


PAGE. 

NO. 

NAME. 

427 

I 

LL'  FFERTS. 

427 

2 

Chiari. 

427 
428 

4 

Holm. 
Lefferts. 

428 

5 

Von  Ziemssen. 

428 

6 

Morris  Asch. 

7 

HOMOLLE. 

430 
431 

s 

9 

Knight. 

Erasmus  Wilson. 

431 

10 

Pye  Smith. 

431 

431 

432 
4^2 

II 

12 

13 
14 

Gottstein. 
j  A.  Harries  and  j 
1  C.  TVI.  Campbell.  ) 

C.  M.  Campbell, 

432 

15 

Neisser. 

432 

16 

Kaposi. 

432 

17 

Schwimmer. 

432 
434 

18 
19 

Ramon  de  la  Sota. 
Marty. 

438 

20 

TUKCK. 

439 

21 

J.  M.  Hunt. 

444 

22 

MoRELL  Mackenzie 

444 
445 

23 
24 

HlLLIS. 

Thin. 

title  of  work  referred  to. 


Amer.  Journal  of  Med.    Sciences^  vol. 

Ixxv.,  p.  yjo  et  seq.    April,  1878. 
Litpns  Vulgaris  Laryngis.  Viertejahressch. 

fiir  Der?n.  unci Syph.,  ix.  Jahrg.,  Hef.  4, 
1882. 

Quoted  by  Gottstein.    Of.  cit.,  p.  148. 
Archives  of  Laryngol.,\o\.  ii.,  p.  273.  1881. 

f  Cyc.  of  Aledicine,  vol.  vii.,  p.  848.  Eng. 

^  Trans. 

Archives  of  Laryngol.,vo\.  ii.,  p.  273.  1 88 1. 

j  Ves  Scrofulides  de  la  Ahupieuse  Bucco- 

\  pharyngienne.    Paris,  1875. 
Archives  of  LaryngoL,  vol.  ii.,  p.  238.  1 88 1. 

Diseases  of  the  Skin. 

\  Fagge's  Principles  of  Medicine.  London. 
/  1886. 
Up.  cit.,  p.  146. 

Lupus,  etc.    London,  1886. 

Loc.  cit.,  p.  10. 

Private  Letters  to  Dr.  Campbell. 

/Ziemssen's  handbook,  Diseases  of  Skin. 

\    Eng.  Trans.    New  York,  1885. 
Private  Letters  to  Dr.  Caniphell. 

/Ziemssen's  handbook,  Diseases  of  Skin. 

\    Eng.  Trans.    New  York,  1885. 
Netv  York  Medical  Journal.  July  10,  1886. 
Le  Lupus  dti  Larynx.    Paris,  1888. 

Op.  cit.,  Case  170,  Fig.  178,  p.  428.  See 
also  for  comparison  Figs.  171,  173,  and 
176  in  Tiirck's  work. 
Jotirn.  of  Laryngology.    Sept.,  1889. 

\  Journal  of  Laiyngology.    London,  1887- 

\     1888,  vol.  i.,  p.  359,  and  vol.  ii.,  p.  2. 
Jourjial  of  Laryngology,  vol.  iv..  Jan.,  1890. 
Brit.  Med.  Journ.    July  19,  1884. 


CHAPTER  XXL 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 

(Figs.  80  to  S/,  Plate  IX.) 

The  figures  iu  the  text  are  intentionally  given  as  simple  reproductions  of  the  rough 
original  sketches  made  in  the  author's  note-book  or  on  hospital  case-papers.  Finished 
illustrations  are  to  be  found  in  the  coloured  plates.] 

No  throat  affection  has  received  such  an  amount  of  attention 
since  the  introduction  of  the  laryngoscope  as  has  been  devoted  to 
new  formations  in  the  laryngeal  cavity,  and  the  remark  of  Von 
Ziemssen,  that  '  the  literature  of  the  laryngoscopic  period  abounds 
in  recorded  observations  to  a  degree  almost  oppressive/  may  be 
applied  especially  to  this  department  of  laryngology.  The  reader 
who  would  wish  for  the  fullest  information  as  to  the  origin,  patho- 
logical varieties,  and  almost  individually  various  treatment  of 
these  affections  may  be  referred  to  the  works  of  ^Czermak  (1863), 
2Tiirok  (1866),  ^Von  Bruns  (1868),  ^Gibb  (1869),  ^Morell- 
Mackenzie  {1871),  ^Mandl  (1872),  and  numerous  others,  down  to 
^Fauvel,  who  in  1876  published  a  volume  of  nearly  1,000  pages, 
fully  half  of  which  is  occupied  by  a  detailed  account  of  300  cases 
of  growth  under  his  own  care.  The  practitioner,  therefore,  need 
not  be  at  a  loss  for  information  on  the  subject,  and  it  will  indeed 
be  strange  if  he  does  not  find  somewhere  recounted  the  homologue 
of  any  case  which  may  come  under  his  observation,  though  he 
will  be  somewhat  perplexed  by  the  different  lines  of  treatment 
he  is  recommended  to  adopt  by  the  various  authors,  and  the 
variety  of  instruments  he  will  be  advised  to  purchase. 

The  consideration  of  this  interesting  though  decidedly  rare 
form  of  laryngeal  disease — at  least  as  presented  to  the  observa- 
tion of  general  physicians  and  surgeons — will  in  the  present  work 
be  limited  to  the  consideration  of  comparatively  few  practical 
points,  with  illustrative  delineations  of  the  laryngoscopic  appear- 


448  DISEASES  OF  THE  THROAT  AND  NOSE, 


ances  and  brief  notes  of  cases  likely  to  be  of  diagnostic  and  thera- 
peutic value. 

This  chapter  is,  moreover,  confined  to  discussion  of  that  class  of 
laryngeal  growth  which  may  be  considered  as  benign — benign,  I 
mean,  in  a  cHnical  as  well  as  a  pathological  sense.  The  principal 
clinical  differentiation  is  that  of  non-recurrence,  and  is  for  the 
most  part  a  serviceable  one.  Nevertheless,  a  small  class  of 
laryngeal  papillomata  exists  in  which  the  growths,  though  truly 
benign,  nevertheless  recur.  Such  are  those  referred  to  in  this 
chapter  as  Cases  lo  and  i6 ;  in  both,  recurrence  in  a  measure 
only  represented  further  development  due  to  previous  imperfect 
removal.  In  the  second  there  was  also  a  distinct  occurrence  in 
fresh  situations.    This  is  characteristic  of  warts  elsewhere. 

Etiology.  —  Without  doubt  the  most  common  cause  is 
hyperasmia,  and  naturally  all  which  tends  to  excite  congestion 
will  predispose  to  the  production  of  new  formations.  Catarrh, 
the  use  of  the  voice  during  catarrhal  attacks,  certain  occupations 
accompanied  by  the  inspiration  of  noxious  vapours,  may  all  be 
considered  predisponents  of  laryngeal  growths. 

The  papilloid  formations  in  tubercular  laryngitis  can  rarely  be 
considered  as  true  tumours,  and  even  those  who  think  otherwise 
would  seldom  counsel  endo-laryngeal  operations  for  their  removal. 
There  can  be  no  doubt,  however,  that  syphilis,  predisposing  as  it 
does  to  obstinate  catarrhal  inflammations  with  a  great  tendency 
to  hyperplastic  deposit,  does  play  an  important  part  as  a  factor 
in  the  production,  not  only  of  condylomata,  but  also  of  true 
laryngeal  neoplasms.  The  case  affording  the  coloured  illustra- 
tions. Fig.  8i,  Plate  IX.,  is  one  of  many  in  point. 

Growths  occur  usually  at  middle  age,  but  may  arise  at  an  early 
period  of  life,  or  may  even  be  congenital.  They  are  naturally  seen 
more  frequently  in  males  than  in  females. 

It  is  almost  impossible  to  give  any  estimate  as  to  the  compara- 
tive frequency  of  occurrence  of  these  formations,  owing  to  the 
fact  that  doubtless  many  cases  of  slight  loss  of  voice  due  to  the 
presence  of  small  growths  have  not  been  investigated  with  the 
laryngoscope.  On  the  other  hand,  those  engaged  in  special 
practice  may  see  a  very  undue  proportion  of  cases  of  growth 
among  the  throat  affections  coming  under  their  notice,  from  the 
fact  that  persistent  impairment  of  voice  is  a  symptom  for  which 
medical  relief  is  early  sought. 

Fauvel  *  does  not  hesitate  to  proclaim  loudly  the  great  frequency 
of  pol3'ps  of  the  larynx,'  because  he  has  seen  300  cases  in  fifteen 
years  ;  but  as  he  does  not  give  the  proportion  of  these  cases  in 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


449 


relation  to  all  other  diseases  of  the  throat  which  he  has  treated, 
nor  the  number  of  other  cases  observed  in  France  during  the 
same  period,  the  fact  as  a  statistic  is  of  little  value. 

Mackenzie  saw  in  ten  years  over  lOO  cases ;  so  it  is  possible, 
even  allowing  for  the  difference  of  area  of  France  and  England, 
that  these  growths  are  more  common  in  the  former  than  in  the 
latter  country.  If  so,  a  cause  may  probably  be  found  in  the  habit 
that  Frenchmen  have  of  speaking  always  a  haute  voix  and  in  the 
open  air,  as  well  as  in  the  abuse  of  tobacco,  and  the  taking  of  in- 
jurious spirituous  drinks. 

^Newman  states  that  they  constitute  only  a  small  proportion 
of  the  chronic  maladies  of  the  larynx,  certainly  not  more  than 
2  or  2|  per  cent.  My  own  experience  leads  me  to  think  that  the 
proportion  is  still  smaller. 

The  following  examples  from  my  note-book  illustrate  the  fact 
of  undue  vocal  effort  and  professional  voice-use  as  a  factor  of  im- 
portance in  the  production  of  neoplasms.  To  avoid  reiteration, 
they  are  completed  by  stating  the  mode  of  treatment  adopted  and 
the  result  thereof.  For  purposes  of  reference,  the  cases  are 
numbered  . 

Casr  I. — Miss  H.  L.,  aged  21,  residing  near  Leicester,  consulted  nic  on  June  2r, 
1879,  on  account  of  a  huskiness  of  the  voice,  and  an  occasional  discomfort  in  swallowing, 
especially  hot  liquids  ox  piquant  dishes,  of  which  she  partook  freely.  Her  voice  had  been 
a  Hne  mezzo-soprano,  but  had  been  much  tried  because  she  had  often  sung  to  excess  after 
a  day's  hunting,  and  in  other  circumstances  very  un- 
favourable to  it.  I  found  a  small  cystic  growth  on  the 
left  side  of  the  epiglottis,  as  indicated  in  the  drawing 
(Fig.  CLXL).  This  was  at  once  incised,  and  caustic 
applied.  There  was  also  a  minute  vascular  prominence 
at  the  free  edge  of  ihe  right  cord  at  its  centre.  Appli- 
cations of  mineral  astringents  always  reduced  the  small 
hyperremic  growth  on  the  cord,  and  gave  improvement 
to  the  speaking  voice  ;  but  the  singing  voice  was  never  Fig.  CLXI. 

restored.  I  saw  this  patient  occasionally  for  several  years,  and  observed  that  the 
neoplasm  remained  for  the  most  part  in  a  passive  condition  :  she  resigned  herself  to  her 
discomfort,  and  did  not  care  to  undergo  the  fatigue  of  treatment.  The  growth  on  the 
epiglottis  q'ute  disappeared  after  the  first  incision  and  cauterization. 

Case  2. — Captain  S.,  aged  49,  who  had  served  in  a  cavalry  regiment  for  some  years  in 
India,  but  had  retired  nearly  ten  years,  consulted  me  on  June  4,  1880,  on  account  of  an 
occasional  loss  of  voice  and  tickling  cough,  which  had  existed  for  fifteen  years.  Plis 
laryngeal  condition  was  identical  with  that  depicted  on  Fig.  83,  Plate  IX.,  there  being 
a  small  vascular  polyp  attached  by  a  small  pedicle  to  the  right  cord  which  flapped  up 
on  phonation.  It  was  quickly  removed  by  the  Sponge  propang,  applications  of  chloride 
of  zinc  being  made  for  a  few  days  after,  with  the  result  that  the  cough  was  entirely 
removed,  and  the  voice  became  stronger  and  more  certain. 

Case  3.— Mr.  T.  J.,  aged  60,  formerly  a  sergeant  in  the  army,  and  still  drill-sergeant 
to  a  Volunteer  corps,  keeping  also  a  public-house  in  Carmarthenshire,  consulted  nie  on 
June  13,  1879,  on  account  of  complete  loss  of  voice  for  six  weeks,  with  gradually 

29 


450 


DISEASES  OF  THE  THROAT  AND  NOSE. 


increasing  hoarseness  for  eighteen  mouths.  Had  not  always  been  temperate,  and 
acknowledged  to  syphihs  m  tarly  life.    He  was  admitted  into  the  Central  London 

Tliioat  and  Ear  Hospital,  and  after  a  series  of  opera- 
tions, principally  with  the  Snare,  his  larynx  was 
cleared  of  the  several  growths  shown  in  Fig.  CLXH. 
His  voice,  though  it  remained  somewhat  gruff,  was 
sufficiently  restored  to  enable  him  to  resume  his  drill 
duties. 

Case  4. — Mr.  C.  B.  L.,  aged  24,  a  theological 
student,  consulted  me,  April  25,  1885,  by  the  advice 
of  Mr.  Taylor,  New  College,  Oxford,  and  of  Dr.  Dyer, 
^  of  Ringwood,  on  account  of  loss  of  voice,  the  cause  for 

^  ^^^'■■"■^ — ^ — — which  was  plainly  apparent  in  the  laryngeal  mirror, 

as  shown  in  the  accompanying  sketches.  Fig.  CLXIH. 
His  history  was  interesting,  and  to  the  following 
effect :  As  a  boy  he  had  sung  treble  in  a  school  chcir 
ttp  to  the  age  of  15  or  16,  singing  through  the  change  of  his  voice  in  chapel,  but  dis- 
continuing to  take  part  in  the  glee  club  of  his  school.    His  voice  on  settling  became 
baritone.     Commenced  singing  again  with  Mr.  Taylor  on  going  to  Oxford,  but  he 


Fig.  CLXH. 


Fig.  CLXHI. 

suffered  frequently  from  hoarseness.  His  vocal  disability  had  become  permanent  since 
the  previous  Michaelmas  Day  (September,  1884).  For  some  time  previously  had  lost 
all  power  of  producing  soft  notes  in  singing,  and  in  conversation  had  either  to  force  or  to 
pitch  his  voice  very  deeply.  The  growth  was  snared  at  the  first  attempt,  and  purity  and 
strength  of  vocal  tone  quickly  followed. 

Case  5. — E.  A.  S.,  aged  39,  a  schoolmaster,  came  under  my  care  July  13,  1SS5,  on  the 
recommendation  of  the  Rev.  Henry  Arnott,  F.R.C.S. 


Fig.  CLXIV. 


The  patient  stated  that  for  nine  months  his  voice  had  been  becoming  weaker.  The  loss 
of  power  was  always  greater  after  his  work,  and  in  the  evening  would  be  quite  losU 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


451 


He  had  formerly  sung  well  ;  but  his  singing  voice  had  been  gone  for  a  year  or  two,  and 
lately  his  respiration  had  become  impeded.    His  father  had  died  of  asthma. 

I  found  that  his  voice  was  reduced  to  a  hoarse  whisper,  the  cause  of  which  was  quickly 
revealed  by  use  of  the  laryngoscope  (Fig.  CLXIV.). 

He  was  admitted  into  the  hospital  on  July  20,  and  at  once  submitted  to  opetativc 
treatment  by  the  snare.  On  removal  of  the  growths  on  his  vocal  cords,  it  was  observcvl 
that  there  were  others  situated  beneath  the  glottis.  These  also  were  removed  at  subse- 
quent sittings,  and  the  patient  left  the  hospital  to  return  to  his  vocation  on  August  7. 
He  subsequently  informed  me  that  his  speaking  voice  was  quite  regained,  but  he  has 
not  since  been  able  to  sing.  A  recent  communication  assures  me  that  he  has  continued 
well. 

Case  6. — George  S.,  aet.  39,  a  costermonger,  applied  as  out-patient  at  the  hospital  on 
December  3,  1885,  on  account  of  complete  loss  of  voice.  He  stated  that  his  first  symptom 
dated  from  nine  months  previously,  when  he  complained  of  a  tickling  and  burning  sensa- 
tion in  the  larynx.    His  voice  began  to  '  break '  about  this  time.    It  gradually  became 


FiG.  CLXV. 


weaker  until  the  date  of  his  application.  It  was  now  reduced  to  the  merest  whisper. 
He  complained  of  a  slight  dry  cough,  referred  to  a  desire  to  clear  his  throat.  His 
breathing  was  somewhat  short  and  laboured  when  he  first  woke,  and  both  it  and  his 
power  of  swallowing  were  worse  after  use  of  his  voice. 

On  laryngoscopic  examination  (Fig.  CLXV.)  a  large  pendulous  and  semi-transparent 
growth  was  seen  to  occupy  the  anterior  half  of  the  larynx,  and  was  apparently  attached 
to  the  left  vocal  cord. 

The  patient  was  demonstrated  to  my  class  on  that  day,  and  on  December  7  it  was, 
entirely  removed  at  the  first  attempt  with  a  Gibb''s  Snare.  On  removal  it  at  once  col- 
lapsed, and  was  shown,  as  had  been  suspected,  to  be  cystic  in  character.  The  contents, 
which  were  clear  and  colourless,  were  probably  serous.  The  patient  at  once  spoke  with 
phonetic  tone,  and  ten  days  after,  in  spite  of 
instructions  to  the  contrary,  he  resumed  his 
occupation,  and  commenced  to  '  call '  in  the 
streets.  The  result  was  that  he  presented 
himself  on  January  ii,  1886,  with  a  conges- 
tion of  his  left  cord,  and  a  slight  swelling  at 
the  point  of  attachment  of  the  growth.  He 
was  admitted  an  in-patient  for  a  fortnight,  so 
as  to  give  him  complete  vocal  rest.  His  larynx 
A'as  touched  daily  with  a  solution  of  chloride 
of  zinc,  and  the  Leiter  cold  coil  applied.  On 
January  25  he  was  discharged  cured. 

Case  7. — Fig.  CLXVI.  represents  the  laryn- 
geal condition  of  a  gentleman,  Mr.  B.,  aged  27, 

who  consulted  me  for  loss  of  voice  on  December  15,  1885.  He  dated  his  trouble  from 
June  8,  in  tha";  year,  when  after  coaching  his  college  crew  in  a  boat-race  at  Oxford, 


Fig.  CLXVI. 


452  DISEASES  OF  THE  THROAT  AND  NOSE, 


wliich  entailed  much  shouting  from  the  rives-bank,  he  found  his  voice  entirely  gone. 
It  had  not  since  returned,  but,  on  the  contrary,  had  steadily  deteriorated. 

Of  the  eight  cases  affording  coloured  illustrations  to  this  work 
on  Plate  IX.,  two  were  hawkers,  one  a  singer,  and  one  an  actor. 
One  other  case  (No.  9),  to  be  reported  later  in  this  chapter,  arose 
in  a  singer,  so  that  of  twenty-five  cases  of  which  I  give  notes, 
thirteen,  or  just  over  half,  are  directly  attributable  to  vocal  causes  ; 
and  this  is,  indeed,  the  usual  proportion. 

Since  this  question  of  voice-use  is  one  of  great  importance,  it  is 
to  be  noted  that  in  the  foregoing  cases,  taken  indiscriminately 
from  my  own  experience,  one  or  more  examples  of  almost  every 
functional  cause  of  laryngeal  irritation  are  to  be  found. 

Thus  constant  use  of  the  voice  in  close  rooms  with  surrounding 
noise,  as  in  a  schoolmaster,  affords  one  example  (Case  5)  ;  of  the 
same  in  all  conditions  of  weather,  as  in  hawkers  and  coster- 
mongers,  there  are  three  (Case  6,  and  those  of  Figs.  82  and  86, 
Plate  IX.) ;  daily  use  of  the  voice  as  a  choir  singer  (Fig.  83)  ; 
as  an  actor  (Fig.  81) ;  forcing  the  registers  of  the  voice,  as  by 
shouting  or  singing  under  adverse  conditions,  three  (Cases  7,  i, 
and  g)  ;  military  duty,  two  (Cases  2  and  3) ;  continuing  to  sing 
through  puberty,  one  (Case  4). 

These  records  illustrate  more  forcibly  than  any  mere  abstract 
dictum,  the  imperative  necessity  that  exists  for  laryngoscopic 
examination  in  every  case  of  loss  of  voice  that  comes  under 
notice,  whether  or  not  there  appear  to  be  constitutional  or 
functional  explanation,  or  more  directly  visible  causes  in  the 
pharynx,  nares,  etc. 

Pathology. — The  morbid  anatomy  of  benign  neoplasms,  as 
applied  to  the  larynx,  is  very  little  different  from  what  is  known 
of  similar  structures  generally.  The  distinctions  are  chiefly 
clinical,  and  are  amply  discussed  in  my  remarks  on  etiology 
and  semeiology.  I  shall,  therefore,  content  myself  with  enu- 
merating the  principal  varieties  to  be  found  in  this  region  in 
their  order  of  frequency,  and  under  the  head  of  physical  signs 
enumerate  their  macroscopic  appearances  as  seen  in  the  laryngeal 
mirror. 

The  most  common  of  laryngeal  growths  are  papillomaia  or 
warty — single  and  multiple — fibromata  or  fibrous,  fibro-cellular  or 
true  polypi,  cystic,  myxomata  or  mucous,  adenomata  or  glandular, 
lipomata  or  fatty,  and  angeiomata  or  vascular.  Not  unfrequently 
more  than  one  variety  is  found  in  difterent  sections  of  a  specimen. 
The  first  three  kinds  are  the  most  usual,  the  others  are  un- 
common, though  cystic  tumours  are  by  no  means  so  rare  as  was 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


453 


supposed  before  the  almost  simultaneous  publication  of  mono- 
graphs by  ^  Moure  and  Cervesato.  Newman  mentions  eccliondroses 
or  eccliondromata,  but  these  are  usually  outgrowths  from  the 
cartilages  and  of  a  different  character  from  the  intra-laryngeal 
neoplasms  at  present  under  consideration,  which  take  their  origin 
in  the  soft  parts. 

The  most  frequent  situation  for  growths  is  on  the  vocal  cords, 
and  they  are  indifferently  found  on  the  superior,  inferior,  and  free 
borders.  The  character  of  the  neoplasms  in  this  situation  is 
that  of  the  first  five  varieties ;  the  cause  is  chiefly  vocal  abuse, 
and  a  constitutional  dyscrasia  is  by  no  means  a  necessary  or 
usual  predi:iponent.  The  contrary  of  this  last  condition  obtains 
with  regard  to  formations  in  the  posterior  commissure ;  growths 
in  this  position  are  rarely  exhibited  in  a  patient  free  from  syphilitic 
or  tuberculous  taint.  On  the  epiglottis  the  growths  are  usually 
cystic  or  adenomatous.  The  following  is  an  example  of  a 
papilloma  in  this  situation: 

Case  8.— Mr.  C.  H.  G.,  zet.  42,  consulted 
me  on  January  5,  1882,  by  the  advice  of  Dr. 
Scott,  of  Bournemouth,  on  account  of  aphonia^ 
which  had  existed  for  nine  months,  and  super- 
vened on  a  previous  hoarseness  of  four  or  five 
years'  duration.  There  was  no  congh  except  a 
slight  'hemming  '  to  clear  the  throat ;  nor  was 
there  pain  nor  any  other  symptom.  With  the 
laryngoscope  (Fig.  CLXVII.)  a  warty  growth        ^  'f^  '/6H 

was  seen  to  be  attached  by  a  small  pedicle  to  .>w-^'  ■ 

the  left  cord,  and  another  more  sessile  was  CLXVII. 
situated  on  the  epiglottis.    On  removal  by 

S7iare  and  prohang^  both  were  found  to  be  of  the  same  histological  character,  and  co  be  of 
papillary  structure. 

Symptoms:  A.  Functional.  —  Although  it  is  of  interest  to 
describe  the  subjective  symptoms  that  characterize  laryngeal 
growths,  it  is  to  be  understood  that  their  frequency  and  severity 
vary  greatly  with  the  size  and  situation  of  the  new  formation. 
No  diagnosis  can  be  more  than  tentative  which  is  made  by 
observance  of  functional  signs  alone,  and  though  presence  of  a 
growth  may  be  suspected,  its  existence  and  nature  can  only  be 
surely  ascertained  by  physical  (laryngoscopic)  examination. 

Voice  is  impaired  in  nine-tenths  of  the  cases  under  observation, 
and  the  alteration  may  vary  from  slight  hoarseness  to  complete 
aphonia,  there  being  a  characteristic  variation  in  vocal  tone  and 
power  during  the  utterance  of  very  short  sentences.  Another 
vocal  peculiarity,  on  which  Carroll  Morgan  has  dilated,  is  that 
of  diphthonia  or  double  voice,  to  be  seen  in  the  cases  of  small 


454  DISEASES  OF  THE  THROAT  AND  NOSE. 


f^rowths  ;  this  gives  rise  to  interruption  of  the  cords  and  division 
of  the  glottic  chink  into  two. 

Respiration  is  impeded  in  about  one-third  of  the  cases,  and 
the  embarrassment  may  reach  to  serious  dyspnoea  in  about  15  per 
cent. 

Coug'h,  w^hen  present,  may  be  an  indication  of  the  situation  of 
the  growth  at  one  of  the  cough-spots  alluded  to  by  Stoerk 
(p.  92).  Very  frequently  the  act  simply  represents  an  endeavour 
to  relieve  a  sense  of  tickling  or  of  a  foreign  body.  The  expectora- 
tion is  scanty,  and  sometimes  contains  traces  of  blood  or  minute 
portions  of  the  growth. 

Deglutition  is  rarely  affected  unless  the  growth  be  on  the 
epiglottis,  in  the  hyoid  fossa,  or  bordering  on  the  anterior  wall  of 
the  pharynx. 

Pain  is  seldom  a  symptom  of  benign  growths,  though  the 
sensation  of  a  desire  to  get  rid  of  a  foreign  body  is  frequently 
complained  of. 

B.  Physical. — Physical  characters  as  to  colour,  form,  and  tex- 
ture will  vary  not  only  according  to  the  position,  but  also  with 
the  pathological  varieties  of  the  growth. 

Examination  of  the  various  figures  in  Plate  IX.,  and  the 
drawings  in  the  text,  will  show  the  characteristic  laryngoscopic 
appearances  and  the  most  usual  position  of  those  growths  which 
are  more  commonly  witnessed. 

Papillomata  are  to  be  seen  in  Figs.  8i,  82,  84,  and  85,  as  more  or  less  pinic,  grey,  or 
white  excrescences,  with  a  cauHflower-Hke  or  truly  warty  surface.  They  vary  in  size  from 
that  of  a  small  pea  to  dimensions  which  may  obscure  the  glottic  lumen.  They  may  be 
sessile  or  pedunculated. 

Fibromata  (Fig.  86)  are  generally  hard,  but  their  consistence  varies  considerably,  and 
they  are  usually  sessile  and  of  even  contour  ;  but  occasionally  the  surface  is  somewhat  rough. 

Fibro-cellular  growths  or  true  polypi,  sometimes  called  soft  fibromata  (Figs.  So,  S3, 
and  85),  are  usually  small,  and  are  smooth,  red,  and  semi-transparent. 

Cystic  gi'ozvths,  not  given  in  colour,  but  shown  in  outline  in  illustration  of  Cases  i  and  6, 
are  most  common  on  the  epiglottis,  where  they  may  attain  a  considerable  size,  and  are 
generally  of  the  nature  of  retention  cysts.  Their  colour  in  this  situation  partakes  of  that 
of  the  cartilage  with  somewhat  increased  hyperemia. 

Myxomaia  are  rare  ;  they  are  pinker  and  more  translucent  than  papillomata. 

Adenomata  (Fig.  86)  are  also  rare ;  they  are  generally  seen  to  grow  from  the 
epiglottis,  and  give  the  appearance  of  a  more  solid  structure  than  a  cyst.  Their  surface  is 
mamellated. 

Angeioinata  or  vascular  tumours  are  very  uncommon,  and  are  probably  of  the  nature 
of  hiimoryJioids.  A  coloured  illustration  drawn  by  me  is  given  in  Mackenzie's  mono- 
graph on  growths  in  the  larynx.  It  represents  a  dark  bluish-purple  growth  of  nnilbei  ry 
form  and  colour,  and  was  situated  in  the  hyoid  fossa. 

I  am  not  in  the  habit  of  employing  the  laryngeal  sound  for 
further  diagnosis  of  the  situation  or  attachments  of  growths,  for 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


ASS 


such  facts,  if  not  ascertainable  on  examination,  are  soon  revealed 
in  the  treatment  of  the  case.  Nor  is  external  palpation  or  auscul- 
tation of  the  larynx  of  any  diagnostic  value  whatever. 

C.  Miscellaneous. — In  truly  benign  formations  there  is  seldom 
any  external  evidence  of  the  disease,  nor  does  the  general  health 
often  suffer  unless  respiration  or  deglutition  be  seriously  inter- 
fered with. 

Treatment. — As  before  hinted,  the  treatment  of  such  cases 
can  only  be  undertaken  by  those  having  competent  experience  both 
in  examination  and  manipulation  with  the  laryngoscope  ;  but  as 
familiarity  with  the  use  of  this  instrument  is  each  year  becoming 
more  general,  and  the  specialist's  aid  may  not  always  be  available, 
my  desire  is  to  render  this  book  of  service  to  all  classes  of  prac- 
titioners. The  directions,  therefore,  to  be  given  for  treatment  of 
this  as  well  as  of  other  diseases  will  be  such  as  are  at  least  not 
likely  to  do  harm,  and  will  be  found  fully  efficacious  for  the 
majority  of  cases  to  anyone  fairly  experienced  in  introducing  in- 
struments within  the  larynx. 

The  considerations  which  should  guide  the  surgeon  who  under- 
takes this  treatment  were  brought  under  the  notice  of  the  pro- 
fession by  me  in  a  paper  read  before  the  Medical  Society  of 
London,  and  published  in  the  British  Medical  Journal,  May  8th, 
1875.  It  was  reprinted  entire  in  my  last  edition,  and  attracted 
some  attention  both  from  opponents  and  adherents.  Though  still 
firmly  convinced  that  my  conclusions  were  in  the  main  sound,  I 
do  not  again  reproduce  the  article  in  extenso,  partly  for  reasons 
of  space,  and  also  because  the  cautions  then  given  being  now 
more  generally  appreciated,  there  is  no  necessity  for  their  repe- 
tition. 

The  propositions  I  submitted  for  consideration  were  the  fol- 
lowing : 

*  I.  Attempts  at  removal  of  growths  from  within  the  larynx  are 
not  in  themselves  so  innocuous  as  is  generally  believed,  but,  on 
the  contrary,  direct  injury  of  healthy  parts  of  the  larynx,  leading 
to  even  fatal  results,  is  by  no  means  of  unfrequent  occurrence.' 
Of  this  several  examples  were  given.  The  risks  may  be  avoided 
by  the  use  of  guarded  instruments. 

*  2.  The  functional  symptoms  occasioned  by  benign  growths  in 
the  larynx  are  in  a  large  proportion  of  cases  not  sufficiently  grave 
to  warrant  instrumental  interference.'  On  this  point  I  am  willing 
to  admit  that  I  may  have  underrated  the  inconvenience,  pro- 
fessionally and  socially,  of  mere  loss  of  voice  ;  but  I  still  submit 
that  it  is  not  sufficient  to  warrant  operations  which  are  in  any 


456 


DISEASES  OE  THE  THROAT  AND  NOSE, 


sense  dangerous  to  life.  The  truth  of  this  and  of  the  next  pro- 
position has,  indeed,  been  conceded  by  ^^Morell-Mackenzie  in  the 
following  words  : 

'  There  are  a  few  cases  in  which  operative  procedure  is  not  required.  Thus  small 
growths  in  the  epiglottis  or  ventricular  bands,  which  cause  little  or  no  inconvenience,  may 
vi'ell  be  left  alone.  This  remark  especially  applies  to  fibromata,  which  grow  much  less 
quickly,  and  are  more  frequently  arrested  in  their  development  than  other  growths.  In 
these  cases,  all  that  is  necessary  is  to  make  a  periodical  examination  of  the  larynx,  once 
or  twice  a  year,  to  see  that  the  neoplasm  does  not  increase  in  size.  Further,  it  sometimes 
happens  that  where,  in  consequence  of  the  advanced  age  or  occupation  of  the  patient, 
the  voice  is  of  little  importance,  no  treatment  need  be  adopted  unless  the  respiration  be 
also  affected.' 

The  number  of  persons  to  whom  the  advice  (appropriate  to 
those  subject  to  benign  growths  in  other  regions  of  the  body)  to 
watch  and  wait  is  given,  must  be  Very  small ;  but,  without  doubt, 
there  are  a  very  large  proportion  of  cases  Vv^hich  never  require 
treatment,  and,  if  left  to  themselves,  never  assume  a  serious 
aspect.  There  is  no  reason  to  doubt  that,  vv^hile  many  of  these 
formations  remain  thus  stagnant,  a  large  proportion  w^ould,  on  no 
less  authority  than  that  of  Virchow,  if  untreated,  '  frequently  dis- 
appear spontaneously,  being  subject,  as  they  are,  to  slow  atrophy 
and  resorption.' 

*  3.  Many  of  these  new  formations  will  disappear,  or  be  reduced 
by  appropriate  local  and  constitutional  medical  treatment,  espe- 
cially when  of  recent  occurrence.'  The  following  is  an  interesting 
example  out  of  many  I  have  seen  of  a  distinct  cure  of  small 
growths  by  early  local  treatment : 

Case  9. — Miss  T.,  a  student  of  singing,  aged  19,  had  for  three 
months  lost  her  singing  voice,  and  for  two  months  had  been 
distinctly  hoarse  in  ordinary  conversation.  The  condition,  as 
seen  with  the  laryngoscope  at  her  first  visit,  February  3rd,  1875, 
is  represented  on  Fig.  CLXVIIL,  namely,  a  small  growth  on 
the  left  vocal  cord,  surrounded  by  bright-red  localized  con- 
gestion. After  a  week's  daily  application  of  a  solution  of 
chloride  of  zinc,  the  hypersemia  was  removed.  In  a  montli 
she  was  quite  well.  Seen  at  frequent  long  intervals  after,  her 
voice  remained  perfectly  clear. 

•  4.  Recurrence  of  laryngeal  growths  after  removal  per  vias 
nahirales  is  much  more  frequent  than  is  generally  supposed.' 
Doubtless  this  is  sometimes  due,  as  in  Cases  9  and  10,  to  incom- 
plete removal  in  the  first  instance,  but  in  others  from  irritation 
of  a  mucous  membrane  having  a  neoplastic  proclivity.  Case  15 
illustrates  both  these  points,  and  the  experience  of  every  prac- 
titioner would  afford  others : 

Case  10.— Mr.  T.  F.,  a  baker,  first  seen  on  October  22nd,  stating  that  his  voice  had 
been  always  rather  thick,  having  as  a  boy  suffered  from  enlarged  tonsils.    He  had  within 


Fig.  CLXVIIL 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


457 


Fig.  CLXIX. 


the  last  twelve  months  become  hoarse,  and  was  now  almost  voiceless.  Until  three  or 
four  weeks  previously  he  had  been  for  some  months  under  the  care  of  another  practi- 
tioner, who  had  on  eleven  different  occasions  removed  pieces  of  growth,  and  at  the  last 
two  or  three  sittings  he  had  informed  the  patient  that  there  was  the  merest  fragment 
left.  There  is  not  the  slightest  suggestion  that  the  practitioner  stated  other  than  the 
truth  ;  but  it  should  be  mentioned  that  all  this  information  was  not  communicated  by 
the  patient  until  after  he  had  been  examined  and  a  sketch  made  of  his  case  (Fig. 
CLXIX.),  v.'hen  he  exclaimed :  '  Why,  that  is  just  like 
the  drawing  made  before  I  was  ever  operated  upon.'  Re- 
garding what  was  just  now  said  as  to  constitutional  treat- 
ment in  these  cases,  it  may  be  stated  that  this  patient  had 
contracted  primary  syphilis  six  years  previously,  followed 
by  sore  throat  and  skin  eruption,  and  was,  when  first  seen, 
suffering  from  palmar  psoriasis.  He  had,  however,  re- 
ceived no  medical  treatment  whatever  from  his  former 
attendant,  who  told  him  that  the  eruption  on  his  skin  had 
no  more  to  do  with  his  throat  than  would  a  broken  leg. 
^Ir.  Durham,  who  saw  the  case  in  consultation  with  me,  aptly  retorted  :  '  But  you 
would  think  a  broken  leg  had  sometliing  to  do  with  your  throat  if  you  had  hurt  both  with 
one  and  the  same  accident.' 

Case  ii. — Walter  L.,  a  hairdresser,  aged  19,  first  seen  on  the  3rd  of  March,  1876, 
at  the  Central  London  Throat  and  Ear  Hospital.  He  stated  that  he  had  always  been 
subject  to  catarrh,  and,  having  lost  his  voice  during  an  attack  two  years  previously,  had 
never  since  recovered  it.  He  had  attended  for  nearly  a  year  at  the  German  Hospital, 
and  only  on  his  last  visit  had  been  examined  with  the  laryngoscope.  He  had  then 
attended  another  (special)  hospital,  where,  after  removal 
of  his  uvula,  pieces  of  growth  were  evulsed  from  his  larynx 
on  four  different  occasions,  at  intervals  of  from  seven  to 
ten  weeks.  The  largest  piece  was  that  last  removed. 
He  stated  that  his  voice  was  now  worse  than  before  any 
operation  at  all,  but  that  lately  his  breathing  had  become 
laboured.  He  gave  as  his  reason  for  discontinuing  at- 
tendance at  this  last  institution,  that  he  did  not  see  what 
was  the  use  of  these  operations  if  the  tumours  grew  larger 
at  each  interval.  Laryngoscopic  examination  showed  two 

pink  lobulated  and  symmetrical  growths  on  the  vocal  cords  at  their  anteric  insertion 
(Fig.  CLXX.).  There  was  great  thickening  and  irritability  of  the  pharynx  ;  the  larynx  was 
also  extremely  congested,  and  it  was  difficult  to  make  even  an  ordinary  examination. 
Although,  therefore,  this  case  is  brought  forward  to  show  the  strong  tendency  to  fresh 
grow  ±,  even  while  under  treatment,  the  fact  that  any  growth  at  all  had  been  removed 
reflects  the  greatest  credit  on  the  skill  of  the  practitioner  under  whose  care  this  patient 
had  been. 


Fig.  CLXX. 


It  is  worthy  of  remark  that  where  there  is  a  tendency  to  fresh 
growth  in  another  part  of  the  larynx,  or  to  recurrence  in  the 
original  situation  of  the  first  formation,  and  repetition  of  operative 
procedures  is  made,  the  intervals  between  each  successive  recur- 
rence almost  invariably  become  shorter.  This  is  only  what  takes 
place  in  recurrence  of  tumours  in  other  parts  of  the  body. 

'  5.  While  primary  malignant  or  cancerous  growths  are  of 
rare  occurrence  within  the  larynx  itself,  benign  growths  occa- 
sionally assume  a  malignant  and  even  cancerous  character  by  the 


458 


DISEASES  OF  THE  THROAT  AND  NOSE. 


irritation  produced  by  attempts  at  removal.'  This  remark  is  the 
one  which,  above  all  others,  has  met  with  most  opposition.  It 
has,  however,  received  support  from  ^^Solis  Cohen,  ^^Tauber, 
and  others,  and  notably  in  the  history  of  one  of  the  patients  from 
whom  the  late  ^^Dr.  Foulis  excised  the  larynx. 

The  primary  growth  was  a  papilloma,  and  was  removed  by  Dr.  Morell  Mackenzie 
about  five  years  previous  to  the  time  that  he  came  under  Dr.  Foulis's  care  ;  the  papilloma 
was  followed  by  the  epithelioma,  which  was  intrinsic,  and  the  specimen  is  preserved  in 
the  museum  of  the  Glasgow  Royal  Infirmary. 

This  proposition  has,  in  recent  times,  received  the  support  of 
Schnitzler,  but,  on  the  other  hand,  it  has  been  met  with  energetic 
opposition  from  ^*^Semon,  who  adopted  the  plan  of  collective  inves- 
tigation, with  the  result  that  of  8,216  cases  of  benign  papillomata 
submitted  to  treatment,  an  apparent  transformation  from  benign 
into  malignant  growths  is  acknowledged  to  have  been  noticed  in 
32  instances,  or  i  in  every  257  cases — but  only  16  are  admitted  as 
certain,  which  gives  i  in  every  513  cases.  I  cannot  agree  with 
the  author's  conclusions  that  ^  it  must  be  at  once  admitted  that  if 
the  operation  had  any  appreciable  influence  in  modifying  the 
nature  of  the  neoplasm,  the  proportion  of  cases  in  which  it  would 
be  observed  would  be  much  greater  than  this.'  Nor  can  I  admit 
that  my  suggestion  *  would  do  much  to  show  that  Von  Bruns'  intro- 
duction of  intra-laryngeal  operations  for  tumours  was  not  the  great 
improvement  it  has  been  held  to  be — but,  on  the  contrary,  a  very 
mischievous  procedure.'  For  with  regard  to  the  first  proposition, 
a  fallacy  is  likely  to  occur,  and  this  in  two  directions  :  (a)  because 
it  is  quite  possible,  and  even  probable,  that  where  cases  believed 
to  be  benign  have  afterwards  turned  out  to  be  malignant,  the 
operators  have  returned  them  under  the  latter  heading ;  and  (b) 
because  a  condition  was  made  that  a  report  must  be  given  of  a 
microscopic  investigation ;  but  it  should  be  borne  in  mind  that  in 
a  fair  majority  of  supposed  benign  cases  no  such  examination  is 
made,  and  not  until  malignity  is  suspected  is  the  microscope  called 
in  to  confirm  or  dismiss  a  doubt.  As  to  the  second  point,  I  do  not 
understand  why  the  law  of  possible  conversion,  by  irritation,  of  a 
benign  into  a  malignant  growth,  should  not  be  admitted  as  readily 
in  the  larynx  as  in  other  regions  of  the  body ;  nor  why  the  chance 
of  such  an  eventuality  should  be  held  to  be  criminal  in  intra-laryn- 
geal surgery  by  exception.  On  the  whole,  while  I  am  prepared  to 
admit  that  my  experience,  which  was  not  derived  solely,  or  indeed 
mainly,  from  my  own  practice,  may  have  been  exceptionally  unfor- 
tunate, I  shall  never  regret  that  I  brought  the  question  under  the 
notice  of  the  profession. 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


459 


*  6.  The  instruments  most  generally  now  in  use  are  far  more 
dangerous  than  those  formerly  employed.'  On  this  point  thj 
reader  is  referred  back  to  page  130  for  information  as  to  the  in- 
struments which  I  recommend  and  employ. 

'  7,  and  lastly.  The  cardinal  law,  that  **  an  extra-laryngeal 
method  ought  never  to  be  adopted  unless  there  be  danger  to  life 
from  suffocation  or  dysphagia,"  should  be  applied  with  equal 
force  to  intra-laryngeal  operations  ;  and  it  is  a  subject  worthy  of 
consideration  whether,  in  many  cases,  tracheotomy  alone  might 
not  be  more  frequently  performed — a,  with  a  view  of  placing  the 
patient  in  safety  when  dangerous  symptoms  are  present ;  b,  in 
order  that  the  larynx  may  have  complete  functional  rest ;  and,  c, 
as  a  preliminary  to  further  treatment,  radical  or  palliative.' 

If  the  truth  of  the  previous  propositions  has  been  proved,  there  is 
not  much  necessity  for  enlarging  on  this  one.  It  is  only  necessary 
once  more  to  impress  the  importance  of  a  more  general  study  of 
the  laryngoscope,  and  of  its  use  at  an  early  stage  in  every  case  of 
alteration  of  voice  ;  of  the  early  treatment  of  hypersemia  of  the 
larynx,  remembering  that  it  is  the  most  general  forerunner  of 
growths  ;  of  the  early  and  active  local  application  of  topical  astrin- 
gent applications  to  such  new  formations ;  of  the  administration 
of  suitable  medicinal  remedies  when  there  is  evidence  or  pre- 
sumption of  any  constitutional  cause  or  complication  ;  and  of  the 
non-instrumental  interference  with  these  formations  for  mere 
symptoms  of  inconvenience,  or  at  least  the  avoidance  of  unguarded 
forceps — whether  for  *  evulsion '  or  *  crushing ' — of  scissors,  or  of 
knives,  having  always  in  view  the  dangers  they  may  inflict  on 
healthy  structures,  and  the  fear  that  traumatic  irritation  may 
only  make  the  disease  worse,  rather  than  better. 

The  following  is  the  course  of  operative  measures  we  pursue  : 

Education  of  the  larynx,  combined  with  the  administration  of 
bromides  and  the  sucking  of  ice,  so  often  adopted  in  earlier  days, 
was  required  in  order  to  overcome  reflex  sensibility;  and,  in  other 
circumstances,  local  anaesthesia,  by  painting  of  chloroform  and 
morphia,  a  tedious  and  by  no  means  always  an  innocuous  pro- 
cedurC;  are  all  now  unnecessary.  Having  decided  to  remove  a 
growth,  cocaine  is  first  appHed  by  means  of  a  cotton-wool  brush 
to  the  fauces  and  to  the  larynx  directed  by  the  mirror. 

Experience  seems  to  show  that  it  is  better  to  make  two 
or  three  repeated  applications,  at  intervals  of  six  or  eight 
minutes,  of  a  5  or,  at  most,  10  per  cent,  solution,  than  to 
employ  those  of  greater  strength,  since  these  last  are  some- 
times attended  with  toxic  symptoms.  Once  or  twice  where 
applications  of  this  nature  have  not  been  successful  in  allaying 


46o 


DISEASES  OF  THE  THROAT  AND  NOSE, 


reflex  irritation,  I  have  with  advantage  injected  a  small  quantity 
of  cocaine  subcutaneoiisly.  Local  ansesthesia  being  thus  obtained, 
the  patient  holds  out  his  tongue  with  his  right  hand,  and  the 
surgeon,  handling  the  mirror  with  his  left  hand,  introduces  with 
his  right  the  snare  (Fig.  LXXXVI.  or  LXXXVIL),  or  the 
laryngeal  sponge  probang  (Fig.  LXXXVIIL,  pp.  131  and  132), 
until  he  sees  that  it  has  passed  the  epiglottis ;  he  then,  remem- 
bering the  antero-posterior  inversion  of  the  laryngeal  image 
(Fig.  XXVI.,  pp.  46  and  47),  passes  the  instrument  well  forwards  ; 
this  is  in  the  contrary  direction  to  what  would  appear  to  the 
unpractised  eye  to  be  indicated  by  the  mirror,  and  it  requires 
some  experience  to  overcome  the  tendency  to  pass  it  backwards. 
If  ansesthesia  is  not  complete,  the  larynx  closes  round  the  in- 
strument the  moment  it  enters  the  vestibule,  and  the  surgeon  will 
liave  to  trust  to  his  previously  ascertained  knowledge  of  the 
position  of  the  growth  as  to  whether  he  passes  his  snare  to  right 
or  left,  to  back  or  front,  of  the  larynx.  In  many  cases  there  is 
considerable  spasm,  which  makes  it  difficult  for  the  instrument  to 
penetrate  beneath  the  glottis,  and  some  amount  of  force — or, 
better  still,  a  little  patience — is  required.  I  prefer  the  Latter, 
since  force  ia  the  case  of  a  saare  of  fine  wire,  especially  if  the 
loop  is  large,  may  bend  the  loop  on  itself,  and  there  is  really  no 
occasion  for  hurry ;  the  glottis  is  sure  to  open  in  a  second  or 
two,  and  then  this  difficulty  is  overcome.  If  a  growth  is  situated 
anteriorly  or  on  either  side,  I  place  a  finger  of  my  left  hand 
(having  withdrawn  the  mirror  so  soon  as  I  am  sure  the  in- 
strument is  in  the  larynx)  externally  in  the  corresponding  situa- 
tion, so  as  to  give  a  point  d'appid.  If  the  growth  is  situated 
posteriorly,  the  patient  may  be  asked  to  assist  by  making  the  act 
of  swallowing.  If  a  loop  is  used,  it  is  gradually  tightened  by 
traction,  and  withdrawn  after  the  surgeon  feels  he  has  placed  it 
in  a  favourable  position  for  catching  the  growth  ;  but  if  the 
sponge  is  employed,  it  may  be  rubbed  up  and  down  several  times 
with  considerable  firmness.  Personally,  I  generally  charge  the 
sponge  with  a  solution  of  chioride  of  zinc  or  sulphate  of  copper 
(Form.  65  or  61),  or  the  cocaine  solution  may  be  employed  to 
moisten  it,  with  a  view  of  allaying  after-pain.  On  withdrawal  of 
any  endo-laryngeal  instrument — no  matter  what  the  character- 
spasm  often  occurs,  though  this  symptom  is  less  marked  in  the 
case  of  instruments  incapable  of  '  nipping '  a  cord,  a  cartilage,  or 
a  piece  of  mucous  membrane,  and  its  severity  is  also  modified 
where  cocaine  has  been  previously  well  applied.  A  few  whiffs  of 
chloroform,  which  should  always  be  at  hand,  or  a  sip  or  two  of 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


cold  water,  will  usually  allay  discomfort  of  this  character.  It  is 
not  well  to  repeat  attempts  at  removal  many  times  at  a  single 
sitting,  for  the  threefold  reason  that  (i)  the  larynx  becomes  more 
sensitive  with  repeated  attempts ;  (2)  spasm  is  more  likely  to 
occur;  and  (3)  there  is  a  risk  of  setting  up  inflammation,  and 
possibly  oedema.  Moreover,  the  moral  effect  of  repeatedly  un- 
successful attempts  is  not  calculated  to  improve  the  chances  of  a 
further  trial.  Should  a  practitioner  attempt  to  remove  a  growth 
according  to  the  foregoing  instructions — and  everyone  must  have 
a  beginning — he  will  not  be  less  likely  to  be  successful  by  the 
assurance,  that  if  he  does  not  catch  the  growth,  he  will  not  be 
likely  with  these  guarded  instruments  to  injure  any  healthy  part. 
I  beg  to  repeat  here  what  I  have  previously  stated,  that  since  the 
foundation  of  the  Central  London  Throat  and  Ear  Hospital  in 
March,  1874,  neither  I  nor  any  of  my  colleagues,  present  or  past, 
have  ever  used  an  unguarded  instrument.  But  while  this  is  the 
course  of  treatment  which  I  personally  pursue  as  the  result  of  a 
long  and  extensive  experience,  supported  by  that  of  my  colleagues, 
I  am  not  prepared  to  deny  that  brilliant  results  may  be,  and  are  daily, 
attained  by  the  use  of  forceps,  according  to  the  pattern  of  Mac- 
kenzie, Fauvel,  etc.  X  only  think  the  risk  of  injury  from  them  is 
greater  than  with  the  snare,  and  as  I  have  always  found  the 
latter  in  every  way  efficient,  I  still  continue  to  employ  it  almost 
exclusively. 

A  few  cases  have  already  been  recorded  in  which  treatment 
has  been  successfully  employed  on  the  lines  I  have  indicated, 
and  I  now  add  a  few  more  simply  to  show  that  the  milder 
measures  are  not  less  efficacious  or  rapid  than  the  bolder  ones 
adopted  by  others. 

Case  12. — Mr.  G.  H.,  aged  70,  first  consulted  me,  June  5,  1879,  account  of  gradual 
loss  of  voice,  which  had  commenced  two  years  previously.  The  present  vocal  state  was 
one  of  almost  complete  aphonia  ;  no 
pain  was  experienced,  but  great  effort 
was  required  at  every  attempt  to  speak. 

The  cause  of  his  condition  is  shown 
in  Fig.  CLXXI. 

There  was  a  large  growth  on  the 
edge  and  upper  portion  of  the  anterior 
two-thirds  of  the  right  cord,  and  a 
smaller  one  beneath  the  same  cord  at 
its  posterior  part. 

After  consultation  with  my  late 
colleague,  Llewelyn  Thomas,  he  was 
placed  under  treatment ;  by  far  the 
larger  portion  of  the  growths  was  removed  by  the  snare,  and  the  voice  greatly  improved 


DISEASES  OF  THE  THROAT  AND  NOSE, 


the  patient  was  not  inclined 


in  tone  and  freedom  ;  but  on  account  of  Ivs  advanced 
to  persevere  to  a  complete  eradication. 

Case  13. — ^J.  V.,  aged  42,  a  police  constable,  came  under  my  care  at  the  Central 
Throat  and  Ear  Hospital,  September  13,  1879,  on  account 
of  loss  of  voice,  which  had  been  gradually  increasing  since 
the  previous  winter,  during  which  he  had  taken  a  severe 
cold  after  night-duty,  and  had  for  some  days  been  completely 
aphonic. 

The  cause  of  his  trouble  was  a  papilloma  on  his  right 
cord  (Fig.  CLXXIL),  which  was  removed  by  the  sponge,  and 
his  voice  quite  restored.  I  have  often  seen  this  man  since, 
and  he  has  had  no  recurrence. 

Case  14. — Mr.  E.  C.  G.  T.,  aged  52,  for  many  years  in 
the  Indian  Civil  Service,  consulted  me,  in  July,  1881,  for 
weakness  and  loss  of  voice,  which  had  troubled  him  for  two 
years.  He  said  it  was  always  worse  at  the  end  of  the  day ; 
but  he  complained  of  no  other  trouble.  He  spoke  with  the 
variable  tones  characteristic  of  laryngeal  growths ;  and  with 
ihc  laryngoscope,  the  two  small  neoplasms,  depicted  in  Fig.  CLXXHL,  were  made 


Fig.  CLXXn. 


Fig.  CLXXHL 

visible.    These  were  easily  rubbed  off  with  a  sponge,  and  the  voice  quite  restored. 

Case  15. — Mr.  H.,  aged  35,  of  no  occupation,  consulted  me,  on  November  20,  1883, 
on  account  of  hoarseness,  almost  amounting  to  aphonia,  which  had  steadily  increased  for 
two  years. 

The  cause  of  this  conditicm  was  a  long  pendulous  growth  at  the  anterior  insertion  of 
the  cords,  and  another  beneath  the  left  at  its  posterior  portion  (Fig.  CLXXIV.).  After 


Fig.  CLXXIV. 


six  operations  at  intervals  of  two  or  three  months,  all  was  removed  by  December  12, 
except  the  small  fragment  shown  in  the  first  sketch  of  that  date ;  but  the  patient  lelt 
town. 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


463 


my 


He  returned  on  August  27.  iJ^86,  with  a  recurrence  in  this  situation  nearly  to  tiic 
extent  of  the  original  growth.  1  was  so  fortunate  as  to  entirely  remove  't  witn  a  siiarc 
on  the  first  occasion,  and  the  voice  was  again  restored. 

Case  16. — Frederick  M.,  aged  ii,  hrst  came  unaer  my  care  in  the  commencement  ol 
July,  1885,  on  the  recommendation  of  Mr.  Brookhouse,  of  Brockley. 

His  mother  stated  that  she  had  noticed  a  gradual  hoarseness  for  the  last  eight  months. 
The  voice  was  now  reduced  to  a  whisper.  There  was  no  other  symptom.  The  laryngo- 
scope showed  a  large  growth  hanging  down  the  glottis 
from  its  anterior  portion.  It  was  difficult  to  make  out  its 
attachments,  but  it  was  believed  to  spring  from  the  right 
cord  (Fig.  CLXXV.). 

A  large  piece  was  removed  with  the  snai  e,  and  it  was 
then  seen  that  the  growth  first  observed  was  attached  to 
each  cord,  and  another  small  sessile  one  was  discovered 
growing  from  the  edge  of  the  left  cord  at  about  its 
centre.  After  a  series  of  operations  with  snare  and 
sponge,  the  boy  left  my  care  in  October  with  hardly  a 
trace  of  growth,  and  with  greatly  improved  voice. 

He  returned  to  me  on  January  26,  1886,  with  return  of 
hoarseness,  and  it  was  then  seen  (Fig.  CLXXVI.)  that 
there  was  (a)  a  return  of  the  growth  on  the  left  cord, 
{b)  a  subglottic  growth  beneath  the  anterior  insertion, 
and  (t)  an  entirely  new  growth  at  the  posterior  wall,  also 
(very  slightly)  beneath  the  level  of  the  cords.  Growths 
were  removed  on  various  occasions,  and  at  the  end  of 
April  he  again  left  my  hands  with  even  a  better  voice 
than  on  the  former  occasion. 

The  boy  was  again  bioiight  to  me  in  October,  1886. 
Again  (Fig.  CLXXVH.)  the  growth  on  the  left  side  had 

returned,  but  was  now  more  on  the  superior  surface  of  the  cord  than  formerly,  and  there 
was  a  fresh  one  rather  larger  on  the  upper  surface  of  the  right  cord.  There  was  no  trace 
of  the  growths  which  had  formerly  existed  at  the  anterior 
and  posterior  commissures.  Treatment  was  resumed,  and 
now  —in  March — the  larynx  is  clear,  with  the  exception 
of  very  slight  thickening  of  the  right  vocal  cord  (Fig. 
CLXXVIIL),  and  the  boy  is  speaking  well.  No  other  in- 
strntnent  except  the  snare  and  Voltolini's  Sponge  has  been 
employed,  though  I  have  been  several  times  tempted  to 
perform  thyrotomy,  so  discouraging  was  the  frequent  re- 
currence, and  so  difficult  were  the  operations,  on  account 
of  the  small  size  and,  even  under  cocaine,  very  sensitive 
condition  of  the  larynx. 

Case  17. — Mary  E.  R.,  aged  15,  engaged  in  a  factory 
in  Bradford,  was  admitted  to  the  hospital  under  my  care 
on  December  31,  1885,  on  account  of  complete  loss  of 
voice,  but  with  no  other  symptom  but  an  occasional 
(aphonic)  cough  when  tired.  The  vocal  deterioration 
had  been  gradual,  and  was  of  twelve  months'  duration. 
Some  recent  attempts  at  removal  of  the  growth  had  been 
attended  with  distress  of  respiration  and  pain.  These 
had  only  lasted  a  fortnight,  and  were  not  present  on 
admission. 

The  laryngoscopic  appearance  is  indicated  in  the  first  of  the  sketches  on  the  next 
page  (Fig.  CLXXIX.). 


Figs.  CLXXV.  and 
CLXXVI. 


Figs.  CLXXVIL 
CLXXVIII 


464 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  growth,  which  was  attached  to  the  right  vocal  cortl,  was  almost  entirely  removed 
by  a  s?tare  at  the  first  attempt  on  January  2,  1886,  and  ihp,  voice  at  once  restored. 

The  girl  was  very  talkative,  and,  moreover,  very  quarrelsome  with  the  other  patients, 
and  passionate;  in  one  of  her  paroxysms  of  temper  the  day  after  operation,  she  shouted 
herself  hoaisj.    On  January  4,  the  larynx  generally  was  somewhat  inflamed,  and  the 


Fig.  CLXXIX. 

cords  considerably  so.  A  slough  abo  was  observed  at  the  point  of  former  attachment 
of  the  growth,  but  nothing  was  left  which  required  removal.  She  was  further  suf- 
fering from  acute  inflammation  of  the  pharynx  and  tonsils.  She  was  ordered  the  cold 
coil,  aconite  internally,  and  frequent  steam  inhalations.  She  was  also  placed  in  a  separate 
ward.  The  inflammation  soon  subsided,  and  she  left  the  hospital  on  February  3  quite 
cured. 

Large  adenomatous  growths,  and  some  others  of  the  nature  of 
sarcomata,  to  be  considered  in  the  next  chapter,  may  be  con- 
veniently and  safely  removed  by  Mackenzie's  Guarded  v/heel 
ecraseur  (Fig.  CLXXX.). 


Fig.  CLXXX.— Guarded  Whekl  Ecraseur  (Mackenzie). 


The  question  of  thyrotomy,  or  division  of  the  external  cartilage 
of  the  larynx,  has  not  been  discussed.  It  should  not  be  performed 
except  for  relief  of  vital  symptoms,  nor  until  an  expert  has  failed 
to  remove  the  growth  by  an  endo-laryngeal  operation,  for  it  is 
very  rarely  indeed  that  the  voice  is  much  better  after  thyrotomy 
than  it  was  before,  and  the  procedure  is  not  without  a  certain 
amount  of  immediate  danger  to  life.  Occasionally,  however,  as 
in  a  case  at  present  under  my  care,  in  which  there  is  a  ridge-like 
papilloma  attached  to  the  whole  length  of  the  vocal  cord,  no 
intra-laryngeal  treatment  would  be  successful.  It  occurs  in  a 
child  aged  eight,  and,  as  respiration  is  seriousl}^  embarrassed, 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


465 


I  intend  performing  thyrotomy.  Certain  foreign  practitioners 
have  not  hesitated  to  divide  at  one  operation  two  or  three  rings 
of  the  trachea,  the  cricoid  cartilage,  the  crico-thyroid  membrane, 
the  thyroid  cartilage,  the  thyro-hyoid  membrane,  and  even  the 
hyoid  bone,  for  removal  of  a  small  and  non-malignant  growth 
causing  but  little  annoyance  ;  and  all  this  with  apparently  no 
thought  of  such  a  consequence  as  perichondritis  or  caries.  In 
many  cases  where  there  is  dyspnoea — the  only  symptom  which 
appears  to  warrant  interference  capable  of  leading  to  fatal  results 
—tracheotomy,  whether  as  an  only  step,  or  as  preliminary  to 
other  measures,  should  much  more  frequently  be  adopted. 

In  benign  neoplasms  tracheotomy  is  sometimes  necessary  where, 
the  growths  being  situated  on  the  under-surface  of  or  beneath  the 
vocal  cords,  attempts  at  removal  set  up  suffocative  spasm.  In 
such  a  case  it  is  better  to  perform  tracheotomy  early  and  at 
leisure,  after  a  mild  warning,  than  to  have  to  do  so  as  a  matter  of 
urgency.  After  the  operation  the  growths  can  not  unfrequently 
be  removed  from  below  the  glottis  through  the  external  tracheal 
orifice.  The  operation  is  also  sometimes  necessary  in  a  case  of 
multiple  congenital  papillomata,  as  a  preliminary  to  thyrotomy 
or  other  procedure.  ^^Hunter  Mackenzie  and  others  have  re- 
corded a  case  in  which  tracheotomy  having  been  performed  on 
children  on  account  of  laryngeal  growths,  the  tube  could  be 
permanently  removed  at  the  end  of  a  year  because  the  growths 
had  spontaneously  disappeared.  He  states  that  '  it  is  now  about 
six  years  since  the  operation  was  performed,  and  during  the  whole 
of  that  time  there  has  been  no  indication  of  any  tendency  to 
recurrence  of  the  growths.  The  voice  is  clear,  the  cords  are 
healthy  in  colour  and  outline,  the  breathing  is  normal,  and  the 
development  of  the  boy  is  good.'  This  case  affords  a  striking 
example  of  the  advantages  of  functional  rest,  and  its  attainment 
by  tracheotomy. 

In  performing  tracheotomy  on  account  of  laryngeal  growths  in 
the  very  young,  in  whom  there  is  reason  to  suppose  the  affection 
to  be  congenital,  there  is  a  source  of  danger  unnoticed  until  it  was 
presented  to  me  in  my  own  practice, namely,  that  of  a  congenital 
pulmonary  atelectasis,  in  consequence  of  which  the  rush  of  air 
through  the  tracheotomy-tube,  so  much  greater  in  volume  than 
the  always  feeble  current  through  the  narrowed  glottis,  sets  up  a 
pulmonary  apoplexy,  and  an  even  fatal  hsemorrhage.  In  my  little 
patient,  aged  three,  the  lungs  were  found  post  mortem  to  be  little 
larger  than  those  of  an  infant  at  birth. 

Lastly,  in  light  of  recent  knowledge  it  may  be  urged  that  all 

30 


466  DISEASES  OF  THE  THROAT  AND  NOSE. 


sources  of  obstruction  to  free  nasal  respiration  should  be  searched 
for,  and,  if  found,  should  be  removed  prior  to  endo-laryngeal  or 
other  operative  procedures ;  for  several  instances  of  recurrence  in 
the  author's  practice  have  only  been  permanently  arrested  after 
removal  of  naso-pharyngeal  tonsillar  hypertrophijes.^^ 

REFERENCES  TO  AUTHORITIES. 


PAGE. 


447 

447 

447 

447 

447 
447 
447 
449 
453 
453 
453 
456 

458 

45S 

458 
458 
465 
465 

465 


NAME. 


CZERMAK. 
TURCK. 

Von  Bruns. 

GiBB. 

Morell-Mackenzie. 

Mandl. 

Fauvel. 

Newman. 

Moure. 

Cervesato. 

Carroll  Morgan. 

Morell-Mackenzie. 

So  LIS  Cohen. 

Tauber. 
D.  FouLis. 
Semon. 

Hunter  Mackenzie. 
Lennox  Browne. 


TITLE  OF  work  REFERRED  TO. 


/  De7'  Kehlkopfspiegel^  2nd  edition.  Leipzig, 
I  1863. 

f  Khmk  der  Krankh.  der  Kehlkopfes.  etc. 
I.    Wien,  1866. 

I'olypen  der  Kehlkops.    Tubingen,  1868. 

\  Diseases  of  Throat  and  Windpipe,  2nd  ed. 

\.    London,  1866. 

Growths  in  the  Larynx.    London,  1871. 

Maladies  du  Larynx,  etc.    Paris,  1872. 

Maladies  du  Larynx.    Paris,  1876. 

Bi'it.  Med.  Journal,  vol.  i.,  p.  579.  1886. 

I France  Medicale^  No.  87.  1880. 

Lo  Sperijnentale,  Heft  i  and  2.  1880. 

Archives  of  Laryngology,  vol.  iii  ,  p.  48. 

Diseases  of  the  Ihroat,  vol.  i.,  p.  315. 

r  Op.  cit.,  p.  581,  1879;   Titans,  of  Internat. 

Med.  Congress,  p.  235,  1881 ;  and  Int4r- 
\    nat.  Cyclopcrd.  of  Surg.,  p.  729,  1884. 
irchives  of  Laryngology,  vol.  iii.,  p.  362. 
/"Quoted    by   Newman,    British  Medical 
\    Journal,  vol.  i.,  p.  815.  1886. 
CentralblattfiirLar.,  etc.    July,  1 388. 
Lancet.    April  6,  1889. 
Trans.  Path.  Society.    1 889. 
j Journal  of  Laryngology,  vol.  v.,  p.  21, 
\  189T. 


CHAPTER  XXIL 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 

(Figs.  88  to  91,  Plate  IX.  ;  Fig.  120,  Plate  XIV. ;  and  Plate  XV.) 

General  Pathology. — Malignant  disease  attacking  the  ordinary 
position  in  the  faucial  region — the  tonsils — has  already  been  con- 
sidered, and  it  has  been  stated  how  rarely  it  is  found  in  the  naso- 
pharynx or  posterior  pharyngeal  wall.  Its  most  common  site  in 
the  pharynx  is  at  the  pharyngo-laryngeal  orifice.  It  may  com- 
mence at  the  tonsil  or  base  of  the  tongue,  invade  the  epiglottis, 
and  travel  down  the  ary-epiglottic  fold,  thus  attacking  both  larynx 
and  pharynx  simultaneously,  and  thereby  affecting  equally  the 
special  functions  of  deglutition  and  of  respiration.  This  frequent 
and  intimate  connection  of  the  pharynx  and  larynx,  when  the 
subject  of  malignant  disease,  is  m.y  reason  for  having  resolved  to 
discuss  the  subject  in  its  entirety,  instead  of  in  two  separate 
chapters. 

Carcinoma  of  the  pharyngo-lar3'nx  is  almost  invariably  of  the 
nature  of  epitheliomatous  ulceration,  and  is,  in  my  experience,  the 
most  common  form  in  which  the  disease  is  manifested  in  this 
region.  The  malady,  when  so  originating,  has  been  denominated 
by  ^Fauvel  cancer  of  vicinity  (voisinage),  a  term  which  well  illustrates 
its  invasion  of  the  larynx  from  the  pharynx,  and  differentiates  it 
from  consecutive,  or  secondary  cancer,  which  would  rather  imply 
that  the  disease  has  originated  in  a  distant  part,  and  has  been 
propagated  in  the  larynx  as  the  result  of  a  general  systematic  infec- 
tion. Cancer,  when  commencing  in  the  pharyngeal  wall  of  the 
larynx,  has  been  well  named  by  ^Krishaber,  extrinsic.  The  disease 
in  this  form  has  also  been  observed  to  invade  the  larynx  from 
the  thyroid  gland. 

Primary  cancer  of  the  larynx  is  that  form  of  malignant  disease 
which  does  not  commence  on  the  outskirts,  but  arises  truly  within 
the  framework  of  the  larynx ;  that  is  to  say,  from  the  ventricle., 


468 


DISEASES  OF  THE  THROAT  AND  NOSE. 


from  the  ventricular  bands,  from  the  vocal  cords,  or  from  the 
laryn^^eal  surface  of  the  epiglottis.  This  form  has  been  termed, 
also  b}''  Krishaber,  intrinsic. 

If  the  term  be  limited  to  carcinoma  of  this  nature,  the  disease 
will  be  found  to  be  much  rarer  than  it  is  considered  even  hy 
Fauvel  and  those  authors  who  have  enlarged  the  limit  of  primary 
malignant  disease.  ^Butlin's  statement  that  'intrinsic  carcinomas 
appear  to  be  much  more  frequent  than  extrinsic  carcinomas  '  is 
open  to  question,  and  his  statistics  on  this  head  are  misleading ; 
because,  rightly  enough  from  his  point  of  view,  he  limits  his 
consideration  to  those  cases  only  in  which  the  nature  of  the 
disease  was  confirmed  by  the  microscope.  It,  however,  is  hardly 
necessary  to  point  out  that  such  a  test  is  applied  with  much  more 
strictness  to  intra-laryngeal  growths — which  are  otherwise  often 
difficult  to  diagnose  from  benign — than  to  pharyngo-laryngeal 
carcinoma  in  which  the  physical  symptoms  are  of  much  more 
certain  significance. 

The  varieties  of  cancer  which  attack  the  larynx  are  mainly  two, 
viz.  (i)  epithelioma,  or  squamous-celled  carcinoma,  and  (2)  sar- 
coma ;  of  these  the  first  kind  is  the  more  common.  In  my  last 
edition  I  spoke  of  medullary  or  encephaloid  cancer  in  the  larynx, 
this  variety  being  recognised  by  Fauvel,  Cohen,  and  most  other 
authors.  This,  as  well  as  scirrhus,  are  also  both  mentioned  in  the 
text-books  of  Bosworth  and  Gottstein  as  varieties  of  malignant 
disease  to  be  found  in  the  larynx.  It  is  probable  that  what  was 
formerly  called  encephaloid  would,  in  most  instances,  be  now 
described  as  a  small-celled  sarcoma,  while  so-called  schirrus,  which 
must  be  very  rare,  would  now  be  represented  as  a  spindle-celled  or 
as  an  alveolar  sarcoma.  Beyond  this  it  may  be  briefly  stated  that 
the  histological  appearances  of  malignant  laryngeal  disease,  what- 
ever the  variety,  differ  in  no  essential  respect  from  those  of  the 
same  forms  when  manifested  elsewhere.  Any  differences  which 
may  exist  in  the  course  of  cancer  when  manifested  in  the  throat 
or  in  difterent  parts  of  the  throat  may,  in  a  measure,  be  due  to 
differences  of  mother-tissue,  but  they  are  in  a  far  greater  degree  in- 
fluenced by  difterences  of  function.  When  it  attacks  a  part  which 
is  concerned  in  deglutition,  it  is  more  rapidly  fatal  than  when  only 
the  vocal  or  even  the  respiratory  portion  of  the  apparatus  is  in- 
volved. It  will  be  presently  shown  that  it  depends  on  no  anatomical 
differences  in  the  glandular  system  in  the  pharynx  and  larynx. 

The  Lymphatic  System  in  Relation  to  Isolation  of  Cancer  in 
the  Larynx. — To  quote  Fauvel,  it  has  generally  been  laid  down 
and  accepted,  *  that  as,  on  the  one  hand,  laryngeal  cancer  is  not 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


469 


propagated  by  infection  in  distant  organs,  so  also  cancer  which 
takes  its  origin  at  a  distance  from  the  vocal  organ,  and  which  in 
time  may  be  generally  developed  in  other  regions,  always  respects 
the  larynx.  It  may  be  said,  then,  that  laryngeal  cancer  confines 
and  localizes  itself  in  the  region  in  which  it  takes  its  birth,  and 
that  cancerous  affection  of  the  immediate  vicinity  of  the  organ  can 
alone  reach  it.'  ^Morell-Mackenzie  says  on  this  point:  *I  only 
know  of  one  instance  in  which  cancer  has  developed  secondarily 
in  other  parts  of  the  body — the  original  disease  having  been  in 
the  larynx.'  The  same  view  has  been  put  in  a  somewhat  dif- 
ferent way  by  Krishaber,  who  has  laid  it  down  as  a  general  rule 
that  the  extrinsic  cancers  affect  the  glands  at  an  early  period,  and 
that  the  intrinsic  cancers  do  not  affect  the  glands.  Mackenzie 
supports  this  view  also,  by  affirming  that  '  the  external  condition 
of  the  neck  seldom  affords  any  evidence  as  regards  (intra)  laryngeal 
cancer.'  I  am  in  entire  agreement  as  to  the  view  that  laryngeal 
cancer  is  never  truly  secondary  in  the  sense  used  by  Fauvel  and 
Mackenzie.  But  clinical  observation  has  had  the  effect  of  causing 
me  to  doubt  for  some  time  past  the  accuracy  of  the  statements  of 
these  authors  regarding  the  indisposition  of  cancer  of  the  larynx 
to  infect  adjoining  glands  or  distant  organs  to  anything  like  the 
extent  with  which  the  doctrine  is  advanced  in  the  words  quoted, 
and  by  other  authors  hardly  less  dogmatically.  And  this  doubt 
has  been  strengthened  by  the  fact  that  until  recently  I  have  not 
found  in  works  on  anatomy  any  explanation  in  the  arrange- 
ment of  the  lymphatics  of  the  larynx  which  should  satisfactorily 
account  for  so  anomalous  a  phenomenon  as  the  isolated  existence 
of  cancer  when  manifested  in  the  larynx.  ^Semon,  speaking  in 
1880  on  the  differences  between  cancer  commencing  in  the 
pharynx  (called  by  him  carcinoma  of  the  larynx  per  contigiiitatem)^ 
and  that  which  commences  in  the  larynx  (endo-laryngeal  car- 
cinoma), stated  by  way  of  explanation,  *  that  the  laryngeal 
lymphatics  are  much  isolated,  whilst  the  pharyngeal  communi- 
cate freely  with  those  of  the  surrounding  parts.' 

Setting  aside  the  circumstance  that  the  case  on  which  he  was 
speaking  was  one  of  endo-laryngeal  cancer  which  manifested 
enormous  glandular  infiltration,  I  am  obliged  to  contravene  the 
accuracy  of  his  anatomical  premise,  albeit  the  misconception  is  a 
very  general  one.  Indeed,  text-book  information  on  the  subject  is 
very  meagre,  and  is  usually  limited  to  a  general  statement  that 
the  lymphatics  of  the  larynx  join  the  deep  glands  of  the  neck. 
But  in  the  work  of  the  distinguished  anatomist,  ^Sappey,  full 
information  is  afforded  as  follows : 


470 


DISEASES  OF  THE  THROAT  AND  NOSE. 


*  Lymphatics  of  the  Larynx  and  of  the  Trachea. — These  vessels  are  remarkable  by 
their  number  and  their  development.  They  are  seen  to  be  especially  numerous  at  the 
level  of  the  upper  orifice  of  the  larynx.  They  spread  themselves  with  extreme  abundance 
over  the  mucous  membrane  of  the  ary-epiglottic  folds.  They  cover  also  all  the  surface  of 
the  epiglottis,  and  every  other  point  of  the  laryngeal  mucous  membrane,  forming,  how- 
ever, in  this  situation  a  network  many  times  smaller  ;  this  mesh  unites  into  two  or  three 
trunks  on  each  side,  which  pass  along  the  middle  portion  of  the  thyro-hyoid  membrane  to 
empty  themselves  into  the  group  of  glands  situated  to  the  right  and  left  of  the  larynx, 
under  the  sterno-mastoid  muscle  {examine  carefnlly  Plate  XV.  at  the  end  of  the  book). 

'  The  mesh  which  is  to  be  seen  on  the  mucous-membrane  of  the  larynx  retains  the  same 
character  in  its  course  along  the  whole  length  of  the  trachea  and  bronchi  (Fig.  CLXXXL). 
The  numerous  small  vessels  which  branch  off  from  them  at  a  right  angle  are  almost  lost  in 
the  glands  which  are  placed  on  either  side,  ladder-wise,  in  relation  to  these  canals.' 

No  pictorial  illustrations  of  this  arrangement  were  given  in  the 
work  from  which  I  have  quoted,  but  this  deficiency  is  amply 

supplied  in  the  splendid  '  Atlas  '  of 
the  same  ''author,  which  was  only 
completed  in  1885,  and  from  which 
I  have  borrowed  and  adapted  the 
explanatory  plate  (No.  XV.)  and 
the  annexed  illustration  (Fig. 
CLXXXL). 

The  following  further  information 
is  afforded  in  this  last-named  volume. 
We  there  learn  that 

'  the  lymphatics  of  the  air-passages,  whether  of 
the  superior,  middle,  or  inferior — in  other  words  of 
(i)  the  nasal  fossae;  (2)  the  larynx;  or  (3)  the 
trachea  and  bronchi — are  more  developed  in  the 
human  species  than  in  any  other  series  of  the 
mammalia ;  and  this  is  especially  true  of  the 
supply  to  the  larynx.  But  there  is  a  general  ten- 
dency for  the  lymph  system  to  diminish  in  the 
subglottic  portions  of  the  larynx,  and  in  its  course 
along  the  trachea.  In  the  superior  orifice  of  the 
larynx  the  vessels  are  multiplied  to  infinity,  and 
when  the  injection  is  well  made,  a  very  rich  and 
elegant  network  may  be  seen  which  stretches  from 
the  median  line  towards  the  ary-epiglottic  folds. 
This  mesh  ascends  also  towards  the  free  border 
of  the  epiglottis,  which  it  covers  completely.  In 
some  cases  it  descends  over  its  anterior  part,  and 
is  prolonged  even  to  the  base  of  the  tongue. 
Inferiorly  it  stretches  over  the  corresponding  wall 
of  the  vestibule  of  the  larynx  to  the  ventricular 
bands,  becoming  more  and  more  attenuated  ien  se 
rarcfiant  de  plus  en  plus). 
'  Posteriorly  the  network  spreads  over  the  ary-epiglottic  folds  and  all  the  posterior  part 
of  the  entrance  to  the  larynx,  passing  from  the  laryngeal  to  the  pharyngeal  mucous 
membrane.    At  this  point  the  mucous  membrane,  which  is  thin  and  non-adherent,  forms 


Fig.  CLXXXL  —  Lymphatics  of 
THE  Larynx  and  Trachea  in 
THE  Adult  {after  Sappey\ 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX.  471 

very  numerous  folds  in  its  reduplications.  Hence  the  mesh  acquires  a  richness  and  a 
tenuity  which  gives  it  an  appearance  without  analogy  in  the  economy.  This  excessive 
multiplicity  of  lymphatic  radicles  accounts  for  the  gravity  of  lymphatic  hypertrophies 
{angioleucites)  in  the  superior  half  of  the  larynx,  of  which  so  little  is  still  known.' 

[This  fact  is  interesting  in  connection  with  the  clinical  importance  my  colleagues  and 
I  have  for  many  years  attached  to  enlargement  of  the  papillae,  and  of  varix  at  the  base  of 
the  tongue  and  epiglottis.] 

*  In  passing  from  the  superior  to  the  inferior  half  of  the  laryngeal  mucous  membrane, 
the  lymphatic  system  is  seen  to  become  abruptly  impoverished,  and  this  is  more  evident 
with  advance  of  age.'    (See  Sappey's  '  Atlas,'  Plate  XLII.,  Nos.  5,  6,  7,  and  8.) 

Sappey  adds,  however,  that  the  vocal  cords  can  be  injected  with 
success  as  well  as  every  other  subglottic  portion  of  the  larynx,  but  not 
always  without  a  block.  The  lymphatic  ducts  of  the  laryngeal 
mucous  membrane  are  divided  into  two  groups — one  on  the 
right  side,  the  other  on  the  left.  Each  of  these  comprises  four 
or  five  vessels  which  converge  towards  the  lateral  walls  of  the 
laryngeal  vestibule,  and  passing  outwards  in  front  of  the  arytenoid 
cartilages,  along  and  through  the  thyro-hyoid  membrane,  to  be 
discharged  into  the  ganglia  situated  around  the  bifurcation  of 
the  carotid  artery.  The  very  minute  radicles  which  flow  from  the 
vocal  cords  are  carried,  some  from  within,  to  empty  themselves 
into  the  sub-epiglottic  mesh  ;  others,  from  above  and  without, 
to  be  lost  in  the  network  on  the  internal  border  of  the  arytenoid 
cartilages.  The  twigs  proceeding  from  the  subjacent  portion  of 
the  laryngeal  mucous  membrane  compass  the  inferior  border  of 
the  cricoid  cartilage.  These  unite  with  those  of  the  trachea,  and 
empty  into  the  very  small  ganglia  which  surround  the  terminal 
portion  of  the  recurrent  nerves. 

Regarding  the  lymphatics  of  the  trachea  and  bronchi,  Sappey  writes: 

*  I  long  believed,  and  it  seemed  in  effect  rational  to  suppose,  that  these  vessels  were  more 
developed  in  the  adult  than  in  the  child,  and  that  they  were  more  so  in  the  great  divisions 
of  the  respiratory  ramifications  than  in  the  secondary  or  third  divisions.  ]5ut  this  opinion 
was  in  flagrant  opposition  to  al!  the  results  of  observation.  It  is,  on  the  contrary,  in  the 
first  stages  of  life  that  the  lymphatic  system  of  the  respiratory  mucous  membrane  is 
seen  to  be  most  developed  ;  and  it  is  in  the  divisions  and  subdivisions  of  the  windpipe 
that  it  attains  tti  greatest  importance.  Hence  diseases  of  these  parts  are  more  frequent 
and  severe  during  infancy.  When  one  studies  the  disposition  of  the  lymphatic  vessels  of 
the  windpipe  of  an  adult,  one  sees  that  they  are  almost  wanting  at  the  upper  part ;  but 
inferiorly,  one  can  inject  them  at  certain  points  without  much  difficulty,  and  thus  obtain 
partial  networks  of  large  mesh  and  of  poor  appearance,  but  nevertheless  very  evident. 
Their  branches  empty  into  the  peri-tracheal  glands.  Lower,  at  the  bifurcation  of  the 
bronchi,  the  meshes  are  closer,  and  can  be  much  better  penetrated  by  the  injected 
mercury.  At  the  first  bronchial  divisions  the  injection  becomes  easy.  We  are  thus 
enabled  to  recognise  that,  in  the  adult,  the  lymphatic  vessels  of  the  air-passages  increase 
both  in  number  and  size  as  they  approach  the  pulmonary  lobules,  in  which  they  arrive  at 
the  perfection  of  their  evolution.' 

The  connection  of  these  lymphatics  with  the  glands  on  each 
side  of  the  trachea  has  been  already  described.    It  is  necessary 


472 


DISEASES  OF  THE  THROAT  AND  NOSE. 


to  add  that  there  is  a  mass  of  small  glands  surrounding  the 
recurrent  nerve  at  the  union  of  the  trachea  and  larynx,  which 
may  attain  considerable  enlargement  under  morbid  influences. 
Finally,  these  peri-tracheal  glands  receive  the  lymphatic  discharges 
of  the  oesophagus  as  w^ell  as  those  of  the  windpipe. 

Granted,  therefore,  that  there  is  some  attenuation  of  the  lympha- 
tics in  the  subglottic  portion  of  the  larynx,  it  cannot  be  conceded 
that  there  is  any  isolation,  nor,  indeed,  is  there  any  clinical  ex- 
perience to  indicate,  that  advance  of  age  plays  any  part  in  confer- 
ring immunity  from  glandular  infiltration,  which  might  perhaps  be 
assumed  on  anatomical  grounds  alone.  The  diminished  size  and 
number  of  the  lymphatics  in  the  subglottic  region  may,  however, 
account,  to  some  extent,  for  the  greater  rarity  of  cancer  in  that 
situation ;  but  it  is  noteworthy  that  in  one  of  the  few  cases  on  record 
of  this  kind,  that  of  ^Norton,  the  glands  were  affected  extensively. 

Sappey's  researches  further  prove  that — 

*  In  the  newly-born  infant,  in  the  first  year  of  life,  and  during  the  whole  period  of 
adolescence,  the  lymphatic  network  of  the  tongue,  palate,  tonsils,  and  commencement  of 
the  larynx,  as  figured  in  Plate  XV.,  is  continued  without  attenuation  or  modification 
along  the  whole  length  of  the  respiratory  passages,  so  that  one  can  inject  without  interrup- 
tion along  the  whole  of  the  respiratory  part,  even  to  the  minute  divisions  of  the  bronchi. 
The  system  is  even  more  developed  in  the  foetus  at  term  than  in  the  adult.  The  contrast 
is  above  all  remarkable  in  the  trachea  ....  This  striking  difference  between  the 
development  of  the  lymphatic  system  in  the  child  and  in  the  adult,  is  a  fact  which 
has  hitherto  escaped  the  researches  of  anatomists,  and  is  deserving  not  only  of  their 
attention,  but,  above  all,  that  of  pathologists.  It  at  once  suffices  to  account  for  the 
frequency  of  diphtheritic  affections  of  the  first  years  of  life,  and  for  their  rarity  with 
advance  of  age  ;  it  explains  also  the  extreme  gravity  of  these  affections.' 

This  last  fact  is  again  a  direct  contradiction  to  another  state- 
ment made  by  Semon  on  the  occasion  quoted.  *  He  believed  that 
the  greater  virulency  of  pharyngeal  diphtheria,  as  compared  with 
laryngeal  diphtheria,  was  due  to  the  same  cause  (isolation  of  the 
laryngeal  lymphatics).'  Clinical  experience  would  generally,  I 
fancy,  be  as  opposed  to  such  a  view,  as  are  the  anatomical  facts 
set  forth  by  Sappey.  On  the  other  hand,  there  is  here  afforded 
an  explanation  of  what  I  have  so  often  insisted  on — the  different 
anatomical  characters  of  all  forms  of  laryngitis  in  children  from 
what  obtains  in  adults. 

It  might  be  added  that  this  circumstance  enables  us  also  to 
understand  that  the  sarcomata  or  lymphadenomata  of  the  larynx, 
which  are  in  effect  the  result  of  excessive  and  perverted  lymphoid 
development,  are  comparatively  common  in  quite  young  people, 
although  carcinomata,  which  pathologically  may  be  viewed  as 
deteriorations  in  growth,  are  for  the  most  part  only  seen  after 
middle  life. 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX, 


Consideration  of  the  foregoing  statements  all  go  to  prove  that 
it  is  by  no  means  true  that  that  portion  of  the  larynx  which  is 
usually  attacked  by  carcinoma  is  ill-supplied  with  lymphatics, 
as  is  often  asserted  as  an  explanation  of  the  so-called  '  respect,' 
but  exactly  the  contrary.    We  also  readily  understand,  through 
the  knowledge  thus  obtained  and  by  reference  to  Plate  XV., 
why  the  epiglottis,  the  ary-epiglottic  fold,  the  hyoid  fossa,  and 
the  pharyngeal  border  of  the  larynx  are  such  favourite  spots  for 
mahgnant  manifestations,  and  why  they  are  much  more  rare 
below  the  level  of  the  ventricular  bands  and  vocal  cords  (see  also 
p.  477).    But  even  without  the  aid  of  the  laryngoscope  one  may 
be  enabled  to  estimate  the  probable  seat  of  a  cancer,  which 
is  not  visible  on  inspection  of  the  back  of  the  mouth  or  base  of 
the  tongue,  by  enlargement  and  induration  of  this  thyro-hyoid 
group  of  glands.    When  the  regions  just  named  are  attacked,  I 
have  found,  and  should  expect  to  find,  that  the  external  condition 
of  the  neck  generally  affords  this  evidence  of  laryngeal  cancer. 
In  such  cases,  also,  the  so-called  cachexia  of  malignancy  is  well 
marked  ;  but  this  is  not  by  any  means  so  confirmed  when  the 
disease  is  of  the  nature  of  a  sarcoma,  nor  is  it  so  uniform  in  the 
rarer  circumstance  of  true  cancer  arising  within  the  cavity  of  the 
lower  half  of  the  larynx.    In  this  last  class  of  case  the  lymphatic 
infiltration  is  to  be  sought  lower  down  in  the  glands  at  the  side 
of  the  trachea  and  bronchi.    Two  cases,  which  I  shall  presently 
relate,  represent  a  class  by  no  means  uncommon,  of  secondary 
deposit  in  the  tracheal  and  bronchial  glands  and  the  apices  of  the 
lungs  ;  and  I  believe  that  if  searched  for  after  death,  this  event 
will  be  found  to  be  the  rule  rather  than  the  exception.    It  may 
not  always  be  that  the  epithelioma  is  at  first  visible  as  an 
ulceration  or  actual  neoplasm,  but  if  at  any  time  present  it  must, 
from  what  we  know  of  the  flow  of  the  lymphatics,  be  primary  ; 
and  I  suspect  that  in  many  cases  of  so-called  cancer  of  the 
bronchial  glands,  employment  of  the  laryngoscope  would  prove 
the  lymphatic  mischief  to  be  secondary  to  a  laryngeal  disease. 
Nevertheless,  on  account  of  the  deep-seated  situation  of  these 
tracheal  and  bronchial  glands,  and  the  frequent  tendency  of 
their  overgrowth  to   develop   inwards   rather   than  outwards, 
presence  of  such  a  condition  is  not  always  objectively  manifested 
during  hfe,  and  thus  its  probability  is  overlooked.    The  direct 
discharge  of  the  lymphatics  of  the  larynx  into  these  tracheal 
and  bronchial  glands,  will  also  account  for  the  almost  uniform 
circumstance  of  paralysis  of  the  vocal  cord  corresponding  to  the 
side  of  the  larynx  which  is  attacked,  when  the  disease  is  unilateral, 


474 


DISEASES  OF  THE  THROAT  AND  NOSE. 


— and  of  both  cords  in  the  case  of  more  diffuse  intra-laryngeal 
cancer — through  gland-pressure  on  the  recurrent  nerves.  I  am, 
indeed,  incHned  to  think  that  some  of  the  cases  of  temporary 
paralysis  which  one  often  sees  associated  with  catarrhal  inflam- 
mation of  the  larynx  are  due  to  sympathetic  enlargement  of  the 
tracheal  and  bronchial  glands  exerting  pressure  on  the  recurrent. 
That  this  may  be  so  in  cancer  is  proved  in  the  first  of  the  two 
following  cases.  This  one  also  aptly  illustrates  the  fact  alluded  to 
by  Risdon  Bennett,  that  *  in  not  a  few  instances,  whilst  the  intra- 
thoracic growth  is  still  of  limited  extent,  the  symptoms  so  closely 
resemble  those  of  aneurism,  as  to  make  the  diagnosis  extremely 
difficult  and  uncertain.  The  more  prominent  symptoms  are 
indeed  in  some  instances,  and  for  a  long  time,  mainly  cardiac' 
Each  of  the  cases  also  illustrates  the  accuracy  of  the  statement 
of  the  same  authority,  that  *  alterations  in  the  external  form  of 
the  chest  are  early  manifest  in  some  cases,  and  not  till  later  in 
others.'  These  remarks  are  taken  from  Sir  Risdon  Bennett's  con- 
tribution to  Quain's  Dictionary,  on  *  Morbid  Growths  of  the 
Mediastinum ;'  and  it  will  be  noticed  that  they  apply  equally  to 
carcinoma  of  the  larynx  with  secondary  glandular  disease  at  the 
root  of  the  neck,  and  to  primary  intra-thoracic  lymphadenoma. 

Case  i. — George  W.,  aged  60,  a  horsekeeper,  applied  at  the  Central  Throat  and  Ear 
Hospital  on  November  27,  1879,  on  account  of  difficulty  of  breathing,  which  had  begun 
a  month  previously,  and  was  becoming  gradually  worse,  with,  for  three  weeks,  increasing 
difficulty  in  swallowing.  There  was  a  history  of  rheumatic  fever  eighteen  years  previously, 
which  was  uncomplicated,  so  far  as  could  be  ascertained,  by  any  heart  trouble.  He 
acknowledged  to  have  indulged  in  stimulants  to  excess,  and  denied  recollection  of  any 
strain  or  violent  effort.  His  •voice  was  somewhat  hoarse  and  high-pitched  ;  his  layyjigeal 
respiration  was  continuously  embarrassed,  and  slightly  stridulous.  He  suffered  with  a 
hoarse,  hacking  cough,  which  was  brought  on  whenever  he  attempted  to  swallow,  and  was 
ac::ompanied  by  much  thick  white  glairy  mucus.  Dysphagia  was  considerable  for  solids, 
but  fluids  were  taken  with  comparative  ease.  He  complained  of  occasional  paiti  in  the 
proecordial  region.  His  radial  pulse  was  84,  the  left  being  more  feeble  and  later  than  the 
right.  The  left  hand  was  cold  ;  the  left  pupil  was  slightly  dilated.  His  respirations 
were  18. 

With  the  laryngoscope  the  posterior  part  of  his  larynx  was  noticed  as  hyper^mic,  but 
free  from  ulceration.    The  left  vocal  cord  was  paralyzed. 

Auscultation  gave  no  evidence  of  disease  in  the  right  lung.  In  the  left  there  was  slight 
comparative  dulness,  with  diminished  expansion  at  the  apex  anteriorly,  without  any 
depression.    The  surface-veins  were  distended. 

The  apex  of  the  heart  was  displaced  downwards  and  outwards  ;  valve-sounds  normal. 
A  bruit  was  heard  near  the  cartilage  of  the  first  rib,  loudest  when  respiration  was  arrested. 

The  dulness  below  the  clavicle,  the  bruit,  the  cardiac  displacement,  the  dyspnoea,  the 
laryngeal  paralysis,  the  dysphagia,  and  the  other  symptoms— of  pulse,  etc.— led  me  to 
form  a  diagnosis  of  aneurism  of  the  aorta  to  the  left  of  the  middle  line  ;  and  this  was  the 
general  opinion  of  my  colleagues. 

On  December  22  ulceration  was  observed  on  the  posterior  surface  of  the  left  arytenoid 
cartilage,  which  was  also  swollen. 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


475 


On  the  1st  January,  1880,  ulceration  was  noted  on  the  pharyngeal  surface  of  the 
larynx,  and  was  diagnosed  as  epitheliomatoiis.  All  this  time  the  difficulty  in  swallowing 
increased  to  complete  aphagia  ;  and  though  the  patient  thought  himself  better  from  Chian 
turpentine,  which  was  at  that  time  being  tried,  emaciation  progressed,  and  he  ultimately 
died  on  May  29  of  asthenia. 

The  autopsy,  made  seventeen  hours  after  death  by  Dr.  Dundas  Grant,  revealed  the  fact 
that  there  was  no  aneiiris?n.  The  bruit  had  probably  been  caused  by  a  small  cancerous 
gland  (examined  microscopically),  which  was  situated  in  the  left  supra-clavicular  fossa, 
and  had  pressed  on  the  junction  of  the  subclavian  and  axillary  vessels.  A  cancerous  gland 
also  pressed  on  the  left  recurrent  nerve,  half-way  down  the  neck. 

The  pericardium  contained  a  few  ounces  of  serum.  There  was  a  small  superficial 
deposit  on  the  surface  of  the  upper  part  of  the  right  lung,  which  was  almost  cartilaginous 
in  density.    The  lungs  were  otherwise  healthy. 

In  the  lajynx  there  was  a  thick  deposit  of  epithelial  cancer  on  the  posterior  surface  of 
both  arytenoids,  also  surrounding  the  pharynx  in  its  lower  fourth  and  at  its  junction  with 
the  oesophagus,  where  the  available  passage  was  reduced  to  about  the  calibre  of  a  flattened 
goose-quill. 

Case  2  was  that  of  Major  ,  aged  65,  sent  to  me  in  December,  1886,  by  Surgeon- 
General  Maclean,  C.B.,  who  had  not,  however,  been  himself  in  attendance  on  the 
patient.  He  stated  that  last  May  he  had  suddenly  lost  his  voice  completely,  when 
apparently  quite  well.  This  symptom  improved  somewhat,  though  the  function  was  never 
completely  regained.  Two  months  later — namely,  in  July — he  had  attacks  of  coughing 
and  suffocation  in  attempting  to  swallow  ;  he  '  felt  he  should  choke  if  he  did  not  get  up 
the  morsel  of  food.'  The  difficulty  was  first  experienced  at  the  commencement  of  the 
gullet,  and  was  not  constant  or  even  frequent  ;  but  in  the  autumn  he  began  to  feel  an 
obstruction  lower  down,  and  the  taking  of  food  was  now  very  difficult.  Beyond  the 
attacks  of  choking  he  had  no  dyspnoea  ;  but  the  voice  was  very  characteristic  of  nerve- 
pressure,  and  the  cough  was  also  very  expressive  of  that  which  we  recognise  as  accom- 
panying cancer.  He  had  great  trouble  from  constantly  hawking  saliva,  and  had  flying 
pains  of  great  severity  about  his  throat,  ears,  and  chest.  He  had  lost  weight  consider- 
ably.   His  respiration  was  noisy  at  night. 

On  examination  with  the  laryngoscope  (Fig.  CLXXXH.),  the  ventricular  bands  and  also 
the  pharyngeal  wall  of  the  larynx  were  seen  to  be  greatly  thickened,  so  that  its  margin  was 
ill-defined ;  and  there  appeared  to  be  bilateral 
abductor  paralysis ;  but  the  left  cord  was  not  visible, 
on  account  of  the  swelling  of  the  corresponding 
ventricular  band.  From  its  resemblance  to  many 
I  have  seen  (note  Fig.  CXXVI.,  p.  312),  I  at  first 
thought  the  case  was  one  of  perichondritis,  and 
doubtless  the  cartilages  were  inflamed  ;  but  on 
examination  of  the  chest  I  found  a  hard  swelling 
at  the  sternal  end  of  the  clavicle,  which  I 
judged  to  be  caused  by  a  growth  in  the  anterior 
mediastinum.  The  limit  of  this  tumefaction 
might  be  defined  by  a  line  drawn  from  across 
the  right  clavicle,  at  about  its  inner  third,  down-  Fig.  CLXXXH, 

wards  and  inwards  to  the  upper  border  of  the 

third  costal  cartilage,  close  to  the  sternum.  There  was  tubular  breathing  and  dulness— 
the  latter  not  excessive — over  this  limited  area,  not  only  on  the  right  side,  but  also  on  the 
corresponding  portion  of  the  left,  which  was  not  swollen.  On  the  left  side,  however, 
there  was  considerable  enlargement,  without  much  induration  of  the  glands  at  the  root 
ot  the  neck.  There  was  tenderness  on  pressure  at  the  supra-sternal  notch,  and  some 
(moderate)  enlargement  in  each  posterior  triangle. 

My  diagnosis  in  this  case  was  malignant  disease,  CQ^nnencing  probably  in  the  larynx. 


476 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  voice  being  first  affected— a  symptom  justly  insisted  on  by  Von  Zienissen  as  of  early 
occurrence,  and  of  great  value.  Later,  the  pharyngeal  aspect  of  the  cricoid  cartilage  had 
been  attacked,  and  hence  the  choking  in  swallowing ;  still  later,  the  intra-thoracic  enlarge- 
ment accounted  for  the  obstruction  lower  down  in  the  oesophagus. 

Subsequent  consultations  with  Dr.  Maclean  and  Dr.  Duncan,  of  Croydon,  confirmed  this 
opinion  ;  and  the  case  is  rapidly  approaching  a  fatal  termination,  the  patient  losing  3  lb. 
in  weight  a  week,  and  the  aphagia  being  now  almost  complete. 

I  find  that  ^Fagge  takes  exception  to  the  assumption  of 
immunity  of  concurrent  glandular  disease,  and  of  cancerous 
infection  of  the  viscera  as  a  rare  occurrence  even  in  intra-laryngeal 
carcinoma,  and  mentions  that  in 

*a  case  which  he  saw  in  1879  with  Mr.  Durham,  and  which  was  yet  in  an  early  stage, 
there  were  already  two  flat  subcutaneous  nodules,  one  near  the  right  clavicle,  and  the  othe  r 
over  the  edge  of  the  left  sterno-mastoid  muscle.* 

Still  more  striking  examples  of  secondary  deposits  in  distant 
organs  of  cancer,  which  commenced  within  the  larynx,  have  been 
afforded  from  time  to  time.  Most  of  them  are  collected  by 
Buthn. 

Sands  reports  a  case  in  which  the  cancer  was  removed  by  thyrotomy ;  the  glands  of 
the  neck  were  not  affected,  nor  was  there  recurrence  within  the  larynx  ;  but  after  death, 
which  resulted  twenty-two  months  subsequent  to  the  operation,  the  lumbar  glands  were 
enlarged,  and  the  left  supra-renal  capsule,  the  left  kidney  and  ureter  were  diseased.  In 
a  second  case,  that  of  ^^Desnos,  there  was  secondary  deposit  in  the  liver;  and  a  third, 
reported  by  ^-Schiffers,  strikingly  resembled  that  of  G.  W.,  just  related  as  occurring  in  my 
own  practice.  The  glands  along  the  jugular  vein  were  extensively  affected,  and  the  lungs 
contained  many  secondary  nodules,  varying  in  size  from  a  pin's  head  to  a  nut.  Further 
cases  of  secondary  infiltration  have  been  recorded  by  ^^Zeissl,  in  which  the  glands  at  the 
back  of  the  oesophagus  were  attacked,  and  of  ^'*Von  Ziemssen,  in  which  the  secondary 
affection  was  in  the  cervical  glands. 

Butlin,  from  an  elaborate  analysis  of  fifty  cases,  states  that 
'  Krishaber's  statement  (as  to  the  non-infecting  character  of 
intrinsic  laryngeal  cancer)  is  not  far  from  the  truth,'  but  there 
are,  as  has  been  seen,  so  many  admitted  exceptions  to  this 
'  law  '  as  to  make  it  really  no  law  at  all ;  the  evidence  is,  indeed, 
quite  as  much  in  favour  of,  as  against  glandular  infection,  and 
of  frequent  '  extension  of  the  disease  through  and  beyond  the 
larynx.'  This  author  thinks  it  'remarkable  that  in  two  of  the 
instances  in  which  dissemination  is  known  to  have  occurred,  the 
abdominal  viscera  and  not  the  lungs  were  affected.'  Just  noting 
that  I  have  here  reported  another  case  with  deposit  in  the  lungs, 
I  would  suggest  that  there  is  nothing  in  our  knowledge  up  to  the 
present  to  justify  us  in  assuming  that  the  abdominal  viscera  are 
more  frequently  attacked  than  the  pulmonary  organs ;  while  as  to 
the  general  infrequency  for  cancer  of  the  larynx  to  be  propagated 
elsewhere,  may  not  we  look  to  the  character  and  function  of  the 
organ,  and  say  that  the  air-passages  performing  a  mechanical  role 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


477 


in  the  vital  economy,  as  opposed  to  the  digestive  duties  of  the 
adjoining  pharynx  and  oesophagus,  are  less  likely  to  convey 
disease  through  absorptive  processes  ?  May  not  also  the  same 
circumstance  account  for  both  the  slowness  and  the  extreme 
malignity  of  laryngeal  cancer  ?  I  do  not  find  any  circumstance 
attending  cancer  in  this  situation  which  should  favour  its  more 
ready  propagation  through  the  circulation,  nor  is  the  supposi- 
tion that  cancerous  material  might  readily  be  taken  into  the 
lungs  directly  through  the  air-passages  very  probable,  in  view 
of  the  special  duties  of  the  cilia  of  the  bronchi.  It  is  far  more 
likely  that  in  cases  of  secondary  deposit  in  the  lungs,  the  lym- 
phatics represent  the  infecting  channel. 

My  own  experience  leads  me  also  to  differ  from  such  an  authority 
as  Butlin  in  his  statement  that  sarcomas  of  the  larynx  do  not 
affect  the  glands,  for  in  three  out  of  four  cases  which  have 
occurred  in  my  own  practice,  and  are  recorded  in  this  chapter, 
the  opposite  condition  obtained.  Butlin  hesitates  to  accept  three 
other  examples  of  sarcomas  infecting  the  glands,  though  two  of 
them  occurred  to  so  experienced  an  observer  as  Fauvel,  and  the 
other  to  Victor  von  Bruns.  I  am  therefore  unable  to  agree  with 
his  theory,  that  '  the  obstacle  to  glandular  affection  in  these  cases 
is  mechanical,  and  that  the  glands  are  not  affected,  simply  because 
the  elements  of  the  tumour  cannot  obtain  access  to  them.'  He 
has  admitted  previously,  that  '  in  the  presence  of  Sappey's  plates  ' 
(see  Plate  XV.),  it  can  scarcely  be  maintained  that  the  absence 
of  lymphatic  vessels  is  the  reason  why  sarcomas  of  the  larynx  do 
not  affect  the  glands  ;  and  it  is  somewhat  difficult  to  understand 
why  this  *  complete  obliteration  '  of  the  lymphatic  vessels,  in  the 
case  of  a  sarcoma  of  the  larynx,  should  be  contradicted  in  the 
case  of  sarcoma  of  the  tonsils,  the  lymphatics  of  which  discharge 
into  the  same  group  of  glands  as  do  those  of  the  supra-glottic 
larynx. 

Fauvel  v/as  the  first  to  draw  attention  to  the  remarkable  pre- 
dominance in  liability  of  the  left  side  of  the  larynx  to  be  attacked 
by  cancer;  but  I  have  observed  that  the  same  fact  obtains  in  con- 
nection with  malignant  disease  of  the  tonsils,  and  even  with 
simple  inflammations.  In  ^^1876  I  pointed  out  also  how  much 
more  frequently  aural  hsematoma  are  manifested  on  the  left  than 
the  right  side,  and  then  suggested  that  this  and  similar  circum- 
stances might  be  explained  by  the  more  direct  flow  and  greater 
force  of  the  circulation  to  the  left  side  of  the  head  and  neck. 

Etiology. — Hereditary  predisposition  appears  to  play  but  a 
small  part  in  the  production  of  cancer  in  the  pharyngo-larynx. 


478 


DISEASES  OE  THE  THROAT  AND  NOSE. 


The  great  predisposition  of  the  male  sex  (i  to  lo)  to  this  dis- 
ease would  rather  point  to  local  irritation  of  occupation,  or  of 
habits  of  smoking  and  spirit-drinking  as  factors  in  its  production. 
Professional  exercise,  over-use,  or  abuse  of  the  voice  does  not 
appear  to  act  to  any.  great  extent  as  a  factor  of  malignant  disease 
in  the  larynx,  common  cause  as  it  is  for  the  development  of 
benign  neoplasms  in  this  region. 

My  own  experience  leads  me  to  the  belief  that  while  simple 
hypercBmia,  the  result  of  over-use  or  abuse  of  the  voice,  is  the  main 
factor  in  the  formation  of  benign  growths,  irritation,  independently 
of  any  such  functional  fault — plus  a  predisposing  condition  of 
the  nature  of  which  we  are  ignorant  at  present — is  the  cause  of 
maligna7icy. 

All  observers  agree  with  the  experience  of  Von  Ziemssen  and 
Fauvel  as  to  the  preponderating  frequency  of  the  ventricle  and 
superior  surface  of  the  vocal  cords  as  sites  of  origin  of  intra- 
laryngeal  epithelioma.  The  large  amount  of  muciparous  glands 
in  the  ventricle,  and  also  the  ciliated  character  of  its  epithelium 
and  of  that  of  the  adjoining  portion  of  the  vocal  cord,  offer  a 
probable  explanation  of  this  circumstance  (see  Fig.  CXXII., 
P-  271). 

Whether  cancer  be  dependent  on  diathetic  or  irritative  causes, 
it  is  worthy  of  consideration  if,  in  the  female  sex,  as  has  been 
long  suggested,  the  breast  and  uterus  do  not  serve  as  outlets  for 
it,  and  its  comparatively  frequent  occurrence  in  these  organs 
account  for  its  rarity  in  the  pharyngo-laryngeal  region. 

Cases  have  been  recorded,  one  especially  by  Blanc,  of 
Lyons,  in  his  very  complete  monograph  on  '  Primary  Cancer 
of  the  Larynx,'  in  which  the  disease  was  clearly  traceable  to 
traumatic  causes — a  possibility  to  which  attention  has  already 
been  drawn  as  likely  to  result  from  the  irritation  of  the  larynx 
caused  by  attempts  at  forcible  removal  of  benign  growths  (p.  457). 
I  shall  presently  relate  a  case  in  which  ears  of  barley  were 
spontaneously  assigned  as  the  exciting  cause  of  a  sarcoma ;  but 
here  equally  with  a  carcinoma,  and  quite  irrespective  of  situation, 
there  must  always  be,  I  imagine,  a  previous  change  of  structure 
which  has  predisposed  to  the  malignancy. 

Cancer  occurs  for  the  most  part  between  the  ages  of  35  and  65, 
but  sarcomata  are  comparatively  common  in  early  life.  The 
following  account  of  the  last-named  disease  in  a  child  contains 
several  features  of  interest  which  justify  its  relation.  For  informa- 
tion after  the  patient  ceased  to  be  under  my  care,  I  am  indebted 
to  Dr.  Leslie  Ogilvie  : 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


479 


Case  3. — Walter  E.,  aged  9,  was  admitted  to  the  Central  Throat  and  Ear  Hospital 
under  my  care,  January  4,  1883,  suffering  from  dyspnoea  with  stridor,  but  without  dys- 
phagia or  loss  of  voice.  This  condition  had  only  existed  for  a  few  weeks,  but  had  rapidly 
become  serious.  His  past  history  was  good,  and  with  the  exception  of  whooping-cough 
and  measles,  his  health  had  been  fair.  The  family  history  indicated  a  tuberculous 
tendency  or  actual  death  from  phthisis  in  several  members.  He  was  a  pale  anxious- 
looking  boy.  When  awake  his  respiration  was  fairly  easy  and  tranquil,  but  during  sleep 
inspiration  was  very  prolonged,  harsh  and  breezy.  Sleep  was  disturbed  every  few  minutes 
or  so  by  difficulty  of  aeration.    Respiratory  rhythm  was  moreover  very  unequal. 

On  examination  of  the  larynx  (Fig.  CLXXXHI.)  an  oval  swelling  was  observed  on  the 
right  pharyngeal  border  of  the  larynx,  with  some  oedematous  swelling  of  the  ary-epiglottic 
folds  of  that  side.    The  cords  acted  fairly  well,  but  were  some- 
what imperfectly  abducted.    Externally  a  tumour,  about  the  size 
of  a  bantam's  egg,  could  be  detected  ;  it  corresponded  to  the 
swelling  seen  in  the  mirror.    To  touch,  the  enlargement  was 
elastic  and  almost  fluctuating,  and  in  the  belief  that  it  was  an  j| 
abscess  an  incision  was  made.    No  pus  escaped,  but  the  swell-  \ 
ing  was  much  reduced,  and  his  breathing  was  improved.  It, 
however,  rapidly  redeveloped,  and  a  piece  as  large  as  a  walnut 
was  removed  by  means  of  the  wheel  ecraseur.    Under  the       YiG.  CLXXXHI. 
microscope  the  structure  was  that  of  a  round-celled  sarcoma. 

Shortly  afterwards,  the  patient  was  removed  from  the  hospital,  and  would  have  been 
lost  sight  of ;  but  through  the  kindness  of  Dr.  Leslie  Ogilvie,  under  whose  care  he  came 
in  May,  1884,  at  the  Paddington  Hospital  for  children,  I  am  enabled  to  complete  his 
history.  At  this  date  the  growth  had  considerably  increased,  and  as  judged  externally 
had  a  diameter,  both  vertical  and  horizontal,  of  2|  inches.  It  was  irregular  in  outline, 
fairly  resistent  to  touch,  and  painless.  Within  the  larynx  the  tumour  was  seen  to  have 
displaced  the  larynx  and  to  compress  the  trachea  ;  there  were  also  observed  several 
pendulous  growths.  Dyspnoea  was  exceedingly  severe,  and  during  night  the  respiration 
was  of  the  noisy  character  that  marks  bilateral  paralysis  of  abduction.  Shortly  after 
admission,  tracheotomy  was  called  for  urgently  on  account  of  spasm.  The  little  patient 
survived  some  months,  and  ultimately  died  of  asthenia  on  July  16,  1885.  Examination  of 
the  parts  removed  on  autopsy  showed  that  there  was  one  large  tumour  4  inches  in  length 
and  3  in  diameter,  and  several  smaller  ones  which  had  compressed  both  the  trachea  and 
gullet  along  their  whole  course  in  the  neck. 

Symptoms. — Both  subjective  and  objective  evidence  of  malig- 
nant disease  will  naturally  vary  according  to  the  part  first  attacked. 
\^^hen  malignant  ulceration  commences  at  the  base  of  the  tongue, 
at  the  epiglottis,  in  the  hyoid  fossa,  in  the  pharyngeal  aspect  of 
the  ary-epiglottic  folds,  or  on  the  posterior  wall  of  the  larynx, 
difficulty  of  swallowing  will  naturally  be  the  first  symptom  for 
which  relief  will  be  sought.  If,  on  the  other  hand,  the  disease 
commences  in  the  immediate  vicinity  of  the  glottis,  the  voice, 
and  later  the  respiration,  will  be  first  affected,  and  very  little,  if 
any,  dysphagia  vv^ill  be  experienced  at  all. 

The  same  may  be  said  with  regard  to  the  physical  symptoms, 
which  naturally  vary  not  only  with  the  origin,  but  with  the 
variety,  and  with  the  progress  of  the  malady. 

Each  symptom  will,  therefore,  be  described  separately,  according 
to  the  point  of  origin  and  the  variety  of  the  morbid  process. 


48o 


DISEASES  OF  THE  THROAT  AND  NOSE, 


A.  Functional.  —  Voice.  — Pharyngo-laryngeal  Epithelioma. — 
Articulation  and  speech  are  characteristically  affected,  from 
diminished  mobility  of  the  tongue  and  epiglottis ;  but  vocal 
changes  are  not  induced  until  the  disease  has  reached  the  larynx. 
This  it  does  either  by  pushing  the  arytenoid  cartilage  of  the 
affected  side  out  of  the  way,  and  so  mechanically  interfering  with 
its  action  ;  by  infiltration  and  ulceration  of  the  intrinsic  muscles  ; 
by  the  disease  invading  the  arytenoid  or  cricoid  cartilages  ;  or, 
lastly,  and  most  usually,  by  the  cancerous  mass  and  accompany- 
ing glandular  infiltration  involving  or  exerting  pressure  on  the 
nerve-supply.  Whatever  the  actual  cause  is,  paralysis  or  im- 
paired mobility  of  the  vocal  cord  of  the  affected  side,  with 
resulting  dysphonia  characteristic  of  such  a  complication,  is  an 
almost  invariable  symptom  of  cancer.    Actual  aphonia  is  rare. 

Intra-laryngeal  Epithelioma  and  Sarcoma. — Here  hoarseness  is 
the  earliest  symptom  of  the  disease,  and  may  have  existed  a  very 
long  time  before  advice  will  have  been  sought.  In  many  cases  it 
occurs  suddenly.  Complete  aphonia  often  results  as  the  disease 
advances,  especially  in  the  epithelial  variety.  Nerve-pressure  is 
not  so  uniform  a  complication  in  sarcoma. 

Respiration.  —  Pharyngo-laryngeal  Epithelioma.  —  Embarrass- 
ment of  the  respiration  is  the  first  symptom  manifested  after 
difficulty  of  swallovv'ing ;  and  shortness  of  breath  may  be  noticed 
even  before  there  is  any  impediment  to  the  passage  of  food. 
If,  however,  only  the  lingual  surface  of  the  epiglottis  is  diseased, 
it  is  quite  possible  that  there  may  be  no  alteration  of  respiration 
whatever. 

Intra-laryngeal  Epithelioma  and  Sarcoma. — Dyspnoea  is  a  symp- 
tom which  quickly  follows  impairment  of  voice  :  a  peculiarity  of 
the  embarrassment  is  that  it  is  experienced  only  on  exertion,  and 
that  comparatively  very  slight  movement  will  cause  shortness  of 
breath,  and  this  even  though  the  disease  be  limited  to  one  side 
only  of  the  larynx :  from  this  it  is  evident  that  the  deeper  tissues 
are  very  early  infiltrated  and  the  muscular  fibres  weakened.  In 
later  stages  severe  paroxysms  of  dyspnoea  are  often  experienced, 
and  are  due  either  to  pressure  directly  on  the  trachea  or  on  the 
recurrent  nerve  by  enlarged  glands,  to  oedema  of  the  glottis,  or  to 
stenosis  of  the  glottic  orifice.  In  the  two  latter  events,  inspira- 
tion is  much  more  impeded  than  ex-spiration. 

Cough  is  not  a  prominent  symptom  of  either  variety  of  malig- 
nant disease,  though  the  usual  sensation  of  a  foreign  body  is 
experienced,  and  gives  rise  to  attempts  at  its  expulsion.  True 
cough  will,  however,  be  a  marked  sign  v>'hen  ulceration  attacks 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


48r 


the  region  of  any  '  cough-spot,'  or  in  the  event  of  a  paroxysm 
due  to  compression  of  trachea  or  nerve.  The  sputa  should  be 
carefully  examined  in  a  suspected  case,  since  it  is  not  at  all  un- 
common for  portions  of  the  malignant  grow^th,  especially  if  it  be  of 
the  epithelial  variety,  to  be  expectorated.  Whenever  this  occurs 
to  any  extent,  there  is  always  temporary  amelioration  of  the  vocal 
and  respiratory  embarrassment.  Traces  of  blood  are  often  seen 
in  the  expectoration  ;  when  the  cartilages  are  affected,  the  mucus 
becomes  foetid,  and  attacks  of  haemorrhage  may  be  frequent, 
severe,  or  even  fatal. 

Deglutition. — Pharyngo-laryngeal  Epithelioma.  —  As  already 
suggested,  difficulty  of  swallowing  is  naturally  the  first  and  the 
most  prominent  symptom  when  the  disease  commences  in  this 
region,  and  it  is  astonishing  how  soon  there  will  be  dysphagia, 
with  but  very  slight  physical  evidence  of  the  disease. 

In  one  case  (No.  5),  a  patient  of  Mr.  Furley,  then  of  West  Mailing,  and  seen  in  187 1, 1  was 
enabled  to  diagnose  carcinoma  before  there  was  any  loss  of  tissue  or  the  least  obstruction 
to  the  passage  of  the  largest  bougie,  but  only  a  small  spot  of  limited  submucous  conges- 
tion on  the  pharyngeal  surface  of  the  posterior  wall  of  the  larynx.  The  only  symptom 
complained  of  was  that  of  obstinate  dysphagia.  Not  till  a  year  later  was  there  actual 
ulceration. 

In  another  (Case  6),  occurring  in  the  spring  of  1877,  in  which  I  had  the  advantage  of  a 
consultation  with  Mr.  Callender,  there  was  the  same  unique  symptom  accompanied  by 
emaciation  ;  the  only  physical  evidence  was  very  slight  ulceration  of  the  free  edges  of  the 
epiglottis,  without  any  thickening  whatever,  though  there  was  some  external  glandular 
infiltration. 

Had  the  ulceration  been  of  syphilitic  or  any  other  non- 
malignant  nature,  the  symptoms  occasioned  thereby  would  hardly 
have  been  noticed.  There  can,  therefore,  be  little  doubt  that 
there  is  enfeeblement  of  the  constrictor  muscles  at  a  very  early 
stage  of  the  disease. 

Difficulty  of  swallowing  is  early  accompanied  by  pain  ;  deglu- 
tition of  solids  becomes  impossible,  fluids  are  ejected,  and  even 
the  saliva  cannot  be  swallowed,  and  is  seen  continually  running 
away  at  the  side  of  the  mouth. 

Intra-laryngeal  Epithelioma  and  Sarcoma.  —  In  this  form  dys- 
phagia occurs  only  as  the  disease  attacks  the  posterior  pharyngeal 
wall,  or  mounts  towards  the  epiglottis  and  its  arytenoid  con- 
nections. It  never  fails,  however,  to  be  present,  and  in  process 
of  time  it  becomes  as  distressing  as  when  the  disease  has  pri- 
marily attacked  the  alimentary  tract. 

Pain. — When  malignant  disease  attacks  the  larynx,  the  same 
acute,  lancinating,  constant  pain  is  present  as  characterizes  the 
existence  of  the  same  form  of  disease  in  other  parts ;  but  it  is 
more  severe  in  extrinsic  or  general  intrinsic  manifestations  than 

31 


482 


DISEASES  OF  THE  THROAT  AND  NOSE, 


in  unilateral  intra- laryngeal  cancer.  In  this  last  form,  ant^ 
especially  when  the  symptoms  are  phonatory  and  respiratory,  pain 
may  for  a  long  time  be  altogether  absent.  Allusion  was  made, 
in  describing  cancer  of  the  tonsil,  to  the  excruciating  pain  so  often 
experienced  in  the  ears  when  the  patient  attempts  even  to  swallow 
his  saliva,  and  Von  Ziemssen  has,  with  great  justice,  insisted  on 
the  presence  of  ear-ache  as  a  positive  argument  in  favour  of  the 
presence  of  laryngeal  cancer.  He  *  attributes  the  pain  shooting 
out  to  the  ear  of  the  affected  side  to  an  irradiation  of  the  irrita- 
tion caused  by  the  neoplasm  in  the  sensitive  fibres  of  the  superior 
laryngeal  nerve  upon  the  auricular  branch  of  the  pneumogastric' 
To  this  it  may  be  added,  that  in  certain  instances  irritation  of  the 
inferior  laryngeal  may  give  origin  to  the  same  symptom. 

B.  Physical. — Pharyngo -laryngeal  Epithelioma  (Figs.  88,  89, 
and  go,  Plate  IX.)  commences  with  a  limited  and  more  or  less 
circumscribed  congestion,  not  differing  in  appearance  from  ordinary 
catarrhal  hypersemia,  except  in  its  limit  of  situation  and  in  the 
thickening  of  the  submucous  tissue :  the  colour  may  deepen  to 
quite  a  purple  scarlet  before  the  deposit  becomes  ulcerated. 
Ulceration  almost  always  commences  at  the  free  edge  of  the 
epiglottis,  or  at  the  edge  of  either  the  glosso-epiglottic  or  ary- 
epiglottic  ligaments;  it  quickly  descends  along  the  ar3^-epiglottic 
folds,  always  preceded  by  infiltration,  and  so  it  comes  to  the 
margin  of  the  larynx,  invades  that  organ,  and  at  the  same  time 
displaces  it,  but  the  boundary-line  between  the  two  passages  is 
seldom  lost.  This  disfigurement  during  the  early  stages  of  the 
disease  is  a  strong  diagnostic  point  in  its  differentiation  from 
syphilis,  in  which  deformity  takes  place  as  the  result  of  cicatriza- 
tion. There  is,  of  course,  never  the  least  attempt  at  repair  in 
malignant  disorder. 

Epithelioma  does  not  always  com.- 
mence  as  an  infiltration  and  proceed 
to  ulceration,  but  may  commence  as  a 
new  growth  of  the  typical  external 
character  of  a  non-ulcerated  squamous 
epithelioma. 

Fig.  CLXXXIV.  represents  such  a  case  (No.  7). 
The  disease  was  seen  to  commence  as  a  full  and 
irregular  outgrowth  of  bright  colour  on  the  right 
pharyngeal  border  of  the  larynx,  and  so  to  press  on 
Fig.  CLXXXIV.  the  right  arytenoid  cartilage,  the  action  of  which  wa:s 

paralyzed,  and  against  the  cricoid.  The  disease  soon 
extended  right  across  the  back  wall  of  the  larynx,  concealing  its  posterior  border  and 
greatly  diminishing  the  orifice  of  the  gullet.  Later,  the  cartilages  underwent  carious 
tlegeneration. 


MALIGNANT  NEOPLASMS  OF  TLIE  LARYNX, 


483 


The  patient  was  a  female,  set.  62,  who  had  suffered  from  difficulty  of  swallowing  for 
eight  months,  followed  by  shortness  of  breath  on  very  slight  exertion,  hoarseness,  and 
pain  extending  to  the  ears.  There  was  enlargement  of  the  cervical  glands  on  the  right 
side,  the  patient  steadily  lost  flesh  and  strength,  and  refusing  to  have  tracheotomy  per- 
formed, died  about  nine  months  after  the  first  appearance  of  the  symptoms.  This  patient 
was  shown  at  the  Pathological  Society  on  February  5,  1878. 

Pharyngo-laryngeal  sarcoma  is  rare,  and  I  can  recall  but  two 
instances. 

The  first  (Case  8)  came  under  my  notice  March  29,  188 1.  The  patient,  Mrs.  D.,  a 
widow,  aged  49,  was  brought  to  me  by  Dr.  Stavely  King  on  account  of  difficulty  of 
swallowing.  She  complained  that  the  first  morsel  of  solid  food  always  went  the  wrong 
way,  but  there  was  no  difficulty  with  fluids.  She  suffered  from  but  slight  cough,  but  was 
greatly  troubled  by  '  phlegm '  of  a  thick  character,  which  gathered  round  the  upper  orifice 
of  the  larynx.  Three  weeks  previously  she  had  spat  up  half  a  pint  of  dark  blood.  Her 
respiration  was  very  noisy,  especially  at  night.  On  laryngoscopic  examination  a  large 
nodulated  growth,  not  unlike  that  illustrated  in  the  previous  case,  but  paler  in  colour, 
more  prominent,  and  of  apparently  firmer  consistence,  was  observed  to  project  from  the 
posterior  surface  of  the  cricoid  cartilage.  The  left  arytenoid  cartilage  was  also  involved, 
and  was  entirely  hidden  from  view  ;  both  cords  were  paralyzed.  There  was  decided 
glandular  infiltration  of  the  neck,  and  I  thought  the  case  was  one  of  epithelioma.  On  her 
second  visit.  April  29th,  exactly  a  month  after  the  first,  the  growth  was  seen  to  have 
increased,  and  she  had  lost  5  lb.  in  weight.  I  removed  a  large  piece  with  the  guarded 
wheel  ecraseur,  which,  on  microscopic  examination  by  Dr.  Dundas  Grant,  proved  to  be  a 
viix-celled  sarcoma.  The  removal  was  very  incomplete,  and  the  benefit  but  temporary. 
The  growth  speedily  returned  to  more  than  its  former  dimensions,  but  a  proposal  ttf 
attempt  radical  removal  was  declined  by  the  patient,  and  I  hea;d  of  her  death  nine 
months  later. 

The  second  case,  under  the  care  of  my  colleague,  Dundas 
Grant,  was  exhibited  by  me  at  the  Medical  Society,  on  March  28, 
1887. 

Case  9. — Edwin  L.,  aged  28,  farm-labourer,  from  near  Cambridge,  applied  in  the 
latter  end  of  February  at  the  Central  London  Throat  and  Ear  Hospital  as  an  out-patient. 
He  complained  of  soreness  and  discomfort  in  the  throat,  which  had  commenced  last 
August,  and  had  slowly  increased  ever  since.  He  attributed  it  to  the  irritation  caused 
by  the  ears  of  barley  getting  into  his  throat  during  harvesting,  he  having  particularly 
noticed  the  annoyance  at  the  time,  and  endeavoured  to  overcome  it. 

He  had  suffered  occasional  pain  in  the  last  three  weeks  only,  and  that  not  excessive. 
The  painful  spot  was  at  the  seat  of  an  enlarged  gland  at  the  angle  of  the  jaws.  Des^hcHtion, 
although  uncomfortable,  was  not  materially  affected.  The  phonetic  character  of  his  voice 
was  good,  but  his  articulation  was  impaired.  He  had  had  no  dyspnoea.  His  weight  was 
9  St.  12  lb.  on  the  day  of  operation. 

On  examination  it  was  seen  that  the  left  tonsil  was  enormously  enlarged,  and  protruded 
far  across  to  the  right  of  the  middle  line  (Fig.  CLXXXV.).  It  was  divided  into  two  distinct 
lobes  by  a  deep  sulcus,  the  anterior  one  being  flap-like  and  less  solid.  On  passing  the 
finger  down  the  throat,  the  growth  was  found  to  be  attached  to  the  epiglottis,  and  to 
extend  downwards  between  the  palato-  and  glosso-pharyngei  muscles  as  far  as  the  hyoid 
fossa.    A  laryngoscopic  view  was  not  possible. 

After  consultation.  Dr.  Grant  on  March  14  removed  the  growth  in  the  following 
manner  :  Solid  cocaine  being  freely  rubbed  into  the  surface,  he  first  applied  a  wire 
ecraseur  ;  but,  on  account  of  the  firm  attachment  of  the  inferior  border  of  the  growth,  the 
loop  constantly  lost  its  grip,  and  only  small  fragments  were  caught.    A  large  portion  of 


484 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  remainder  was  removed  with  Schutz's  new  forceps  (Fig.  CCXXV.,  p.  644)  and 
Lowenberg's  curette,  both  being  instruments  usually  employed  for  posterior  adenoid 
growths;  and  finally  the  raspatory  and  finger-nail,  till  the  whole  surface  was  smooth. 
Cocaine  was  again  applied,  and  the  galvano-cautery  freely  used.  There  was  but  little 
haemorrhage. 


Fig.  CLXXXV\ — Tonsil  before  operation. 


Fig.  CLXXX VI.— Fauces  14  days         Fig.  CLXXXVII.— Laryngoscopic 
after  operation.  view  14  days  after  operation. 

Lympho-Sarcoma  of  Tonsil,  Pharynx,  and  Larynx. 

New  growth  was  observed  in  a  week,  and  in  fourteen  days  had  recurred  to  the  extent 
indicated  in  Fig.  CLXXXVL  In  a  laryngoscopic  drawing  made  also  on  this  date 
(Fig.  CLXXXVII.)  it  may  be  seen  that  the  larynx  is  invaded  actually  to  the  extent  of 
the  epiglottis  ;  but  it  does  not  appear  that  the  left  pharyngo-laryngeal  wall  is  involved, 
although  its  outline  is  obscured  by  the  growth  projecting  across  its  boundaries.  Glandular 
infiltration  is  limited  to  small  and  moderately  hard  swelling  of  one  of  the  thyro-hyoid 
group. 

The  nature  of  the  growth  was  ascertained  by  microscopical  examination  of  fragments 
before  attempts  at  more  complete  removal. 

The  Secretion  of  the  actual  ulcers  is  not  plentiful,  unless  the 
true  cartilages  are  attacked.  There  is  always,  however,  excessive 
reflex  salivation,  which  proves  a  symptom  of  great  inconvenience 
and  even  of  pain. 

Intra-laryngcal  Epithelioma  (Fig.  121,  Plate  XIV.)  is  in  its 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX, 


485 


physical  appearances  characterized  by  the  presence  of  a  tumour, 
ill-defined  in  form,  and  seldom  circumscribed  or  pedunculated — ■ 
otherwise  it  has  at  first  much  the  appearance  of  a  benign  epithe- 
lial formation  ;  the  surface  is  formed  by  irregular  nodules  standing 
out  from  beneath  the  mucous  covering,  and  when  proceeding 
from  the  vocal  cords,  the  growth  is  of  a  white  or  pale  rose-colour, 
though  when  situated  in  other  parts,  its  hue  may  be  often  deep- 
ened. Enlarged  experience  convinces  me  that  this  form  of  cancer 
frequently  commences  in  the  ventricle,  though  it  may  appear  in 
the  laryngeal  mirror  to  originate  from  a  cord.  The  extent  of  the 
disease  is  often  very  difficult  to  determine  with  the  laryngoscope, 
which  affords  a  necessarily  foreshortened  view.  This  is  well 
illustrated  by  comparison  of  the  figures  of  the  laryngeal  image 
(No.  CXC,  p.  495),  and  of  the  removed  portion  (No.  CXCII., 
p.  497). 

As  the  disease  progresses,  the  colour  always  becomes  more 
pronounced,  the  growth  increases  in  size  to  even  enormous 
dimensions,  and  there  are  various  points  of  ulceration.  Still 
later,  the  whole  mass  may  have  the  appearance  of  one  sloughing 
tumour,  from  which,  if  the  cartilages  have  been  diseased,  there 
will  be  abundant  purulent  secretion. 

Laryngeal  Sarcoma  (Fig.  91,  Plate  IX.,  and  Fig.  120,  Plate 
XIV.). — This  form  is  usually  developed  in  the  first  instance  as  a 
firm,  defined  and  non-pedunculated  tumour,  or  it  may  appear  as  a 
more  or  less  uniform  tumefaction  of  the  soft  parts,  or  as  general 
sub-mucous  infiltration ;  it  is  generally  limited  in  its  origin  to  one 
side  of  the  larynx. 

Its  aspect  is  usually,  except  when  proceeding  from  the  ven- 
tricles or  vocal  cords,  smooth  and  round ;  but  in  these  latter 
situations  it  may  assume  the  lobulated  cauliflower  appearance  of 
an  epithelial  growth.  In  colour  it  is  generally  brighter  than  the 
epithelial  variety  ;  it  is  of  soft  consistence,  and  of  very  vascular 
structure  ;  it  is  therefore  liable  to  early  ulceration,  and  to  frequent 
haemorrhages.  As  in  the  case  of  epithelioma,  these  tumours  may 
attain  very  great  size.  On  this  point  of  the  dimensions  of  a 
laryngeal  sarcoma,  my  experience  is  opposed  to  that  of  Cohen 
and  Butlin ;  but  the  cases  I  report  (Nos.  3,  8,  9,  and  10),  and 
many  others  on  record,  attest  its  accuracy. 

Case  10.— The  patient  from  whom  the  specimen  which  affords  the  coloured  illustration 
of  this  form  of  disease  was  taken  was  a  female,  aged  47,  who  came  under  my  hospital  care 
in  October,  1876.  The  nature  of  the  malady  was  diagnosed  by  means  of  the  laryngoscope 
fifteen  months  before  death,  in  January,  1878.  The  first  symptoms  were  hoarseness,  and 
later  almost  complete  aphonia,  then  dyspnoea,  both  constant  and  with  paroxysmal  exacer- 
bations, but  dysphagia  was  never  severe.  Pain,  extending  to  the  ears,  was  an  early  and 
constant  symptom.  ^ 


d86 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  bright-red  colour  and  smooth  lobulated  character  of  the  growth  shown  in  the  coloured 
illustration,  served  to  well  differentiate  the  disease  from  epithelioma,  which,  when  com- 
mencing within  the  larynx,  is  of  a  much  paler  colour  and  of  warty  appearance,  while,  as 
in  the  preceding  case,  when  attacking  the  pharyngo-laryngeal  boundary,  it  commences  as 
an  advancing  intiltration  and  ulceration.    In  sarcoma  ulceration  is  a  late  manifestation. 


These  laryngoscopic  features  are  well  illustrated  in  the  two  drawings  (Figs.  CLXXXVIII. 
and  CLXXXIX. ) ;  the  one  taken  on  first  seeing  the  patient,  the  second  more  than  a  year 
later,  and  shortly  before  death  (see  also  Fig.  91,  Plate  IX.,  and  Fig.  120,  Plate  XIV.). 

Microscopic  examination  gave  clear  evidence  of  the  character  of  the  growth,  which  was 
exhibited  by  me  at  the  Pathological  Society  in  February,  1878,  as  a  specimen  of  encepha- 
loid  cancer  ;  but  with  later  knowledge,  I  have  no  doubt  that  it  was  a  sarcoma.  The 
post-mortem  examination  shows  that  the  disease  was  much  more  limited  to  the  right  side 
than  appeared  on  laryngoscopic  examination,  and  at  the  present  time  I  cannot  but  regret 
that  an  attempt  was  not  made  to  remove  it  by  excision  of  the  affected  half  of  the  larynx. 

The  most  characteristic  physical  feature  of  malignant  disease  of  the 
larynx,  whatever  be  its  variety,  is  the  great  deformity  caused  by 
the  new  formation.  The  tumour  not  only  infiltrates  and  changes 
diseased  portions,  but  pushes  even  healthy  structures  far  out  of 
their  normal  position,  so  that,  as  Blanc  has  well  said,  '  at  a  com- 
paratively early  epoch  of  the  malady  the  alterations  of  the  larynx 
take  forms  so  diverse,  that  not  only  does  one  cancerous  larynx 
not  resemble  others,  but  even  the  same  larynx  examined  at  dif- 
ferent periods  will  often  present  widely  different  aspects.' 

It  is  this  characteristic  displacement  which  may  largely  account 
for  the  severity  of  the  dyspnoea  when  the  glottic  lumen  does  not 
appear  proportionately  narrowed,  and  this  symptom  may  be  more 
frequently  traced  to  mechanical  pressure  and  to  nerve-compression 
than  to  actual  stenosis. 

C.  Miscellaneous. — Externally  there  is  very  frequently,  but 
by  no  means  invariably,  or  in  the  earlier  stages,  considerable 
glandular  infiltration.  In  pharyngo-laryngeal  cancer,  this  circum- 
stance is  of  almost  constant  occurrence,  and  often  proceeds  to 
suppuration ;  but  in  intra-laryngeal  malignant  disease,  it  is  some- 
times apparently  absent.  Glandular  enlargement  may  then  be  felt 
lower  down  along  the  windpipe,  or  at  the  root  of  the  neck,  or 
there  may  be  dulness  at  the  upper  part  of  the  chest.   Even  where 


October  14,  1876. 
Fig.  CLXXXVIII. 


December  6,  1877. 


Fig.  CLXXXIX. 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


487 


there  is  no  physical  indication  of  glandular  infection  during  life, 
the  fact  is  freqently  discovered  post-mortem  ;  and  the  same  may  be 
said  regarding  secondary  deposits  in  other  organs.  In  sarcoma  of 
the  larynx  proper,  the  lymphatics  are  said  to  be  not  involved, 
and  such  was  the  condition  in  one  of  the  two  cases  quoted ;  but 
when  a  sarcoma  commencing  in  the  tonsil  extends  to  the  pharynx 
and  invades  the  larynx  by  contiguity,  there  is  no  immunity  of 
this  character.  Of  such  a  variety  of  sarcoma,  I  have  seen  three 
examples.  Sometimes  the  growth  itself  may  be  felt  by  external 
palpation,  especially  when  the  disease  has  attacked  the  thyroid 
and  cricoid  cartilages.  An  instance  of  this  circumstance  was 
related  at  p.  316  in  the  case  of  a  malignant  enchondroma  which 
is  there  described  and  delineated  (Fig.  CXXXIL,  p.  316).  An 
outbreak  of  carcinoma  through  the  surface  of  the  integument  is 
rare,  but  ulceration  of  enlarged  and  infiltrated  cervical  glands 
occasionally  takes  place. 

Wherever  possible,  the  diagnosis  should  be  completed  by  the 
removal  and  repeated  microscopical  examination  of  a  portion  of 
the  neoplasm. 

The  general  symptoms  are  those  common  to  the  malignant 
cachexia,  aggravated  by  the  position  of  the  growth,  and  inter- 
ference with  vital  functions.  Occasionally,  however,  in  the  early 
stages  of  truly  intrinsic  epithelioma  and  of  primary  sarcoma  of 
the  larynx,  the  functions  impaired  are  respiratory  rather  than 
nutritive ;  as  a  consequence,  there  may  be  but  little  general 
emaciation. 

In  the  case  just  narrated  of  the  patient  who  was  under  my  care  in  conjunction  with 
Dr.  Brown,  of  Kentish  Town,  it  was  remarked  at  the  autopsy  that  the  body  was  even 
more  than  usually  well  nourished,  as  far  as  the  presence  of  fat  was  concerned,  though 
the  tissues  had  the  characteristic  pale  and  bloodless  appearance  generally  witnessed  in 
the  victims  of  malignant  disease. 

Prognosis,  Course,  and  Termination. — Malignant  disease 
of  the  larynx,  if  unchecked  by  operation,  is  universally  fatal ;  but 
its  course  varies  considerably,  according  to  its  original  site  and 
pathological  nature.  Small  round-cell  sarcoma,  when  occurring 
within  the  larynx,  grows  slowly,  and  exerts  the  least  amount  of 
constitutional  cachexia  ;  when  manifested  as  an  extension  from 
the  tonsil  the  progress  is  more  rapid.  Spindle-cell  and  myeloid 
sarcomas  exhibit  increased  malignancy.  Epithelioma,  whether 
stratified  or  alveolar,  kills  more  rapidly  than  either,  when  once  in 
a  state  of  active  development — that  is,  of  new  growth  or  of 
ulceration;  but  it  would  appear  in  some  instances  to  lie  long 
dormant.    It  much  earlier  affects  the  general  health  of  the  patient 


488  DISEASES  OF  THE  THROAT  AND  NOSE. 

than  a  sarcoma,  attacking  as  it  does  the  vital  mechanisms  of 
respiration  and  deglutition.  It  would  appear  possible,  from  the 
result  of  at  least  one  case  (the  celebrated  one  of  Bottini),  to 
completely  eradicate  sarcoma  by  extirpation.  In  others  of  a 
similar  pathological  nature,  comfortable  life  has  been  prolonged 
for  some  years  ;  but  the  outlook  of  such  attempts  in  the  case  of 
epithelioma  is  very  unfavourable,  for  however  complete  may  appear 
the  removal,  recurrence  is  invariably  sure  to  take  place  sooner  or 
later.  Attempts  at  eradication  of  pharyngo-laryngeal  epithelioma 
are  universally  ineffectual.  This  last  variety,  interfering,  as  it  does, 
with  deglutition  and  nutrition,  is  always  rapidly  fatal  in  its  course. 

The  direct  causes  of  death  are  much  the  same  as  in  malignant 
disease  in  those  situations  of  the  throat  previously  considered 
(p.  268),  and  life  may  terminate  by  marasmus  or  asthenia, 
asphyxia,  or  haemorrhage ;  or  by  secondary  diseases,  as  pneu- 
monia, or  through  perforation  of  the  oesophagus. 

Treatment. — Remedial  measures  may  be  divided  into — (i) 
Medical,  (2)  Surgical,  and  (3)  Hygienic. 

As  to  the  first,  no  drug  of  which  there  is  present  knowledge  has 
the  least  effect  on  the  career  of  laryngeal  malignancy,  whatever  the 
circumstances  of  site  or  variety,  and  it  is  only  waste  of  time  to 
discuss  the  supposed  efficacy  of  Chian  turpentine,  mercury, 
arsenic,  sulphide  of  calcium,  iodoform,  or  ergot.  Constipation 
is  a  frequent  symptom  of  cancer  in  the  larynx  as  of  other 
regions,  and  relief  of  that  state  by  enemata  or  otherwise  should 
not  be  neglected.  For  the  alleviation  of  pain,  local  applications  of 
solutions  or  insufflations  of  iodoform,  morphia,  or  cocaine  are 
to  be  advocated ;  while  externally  belladonna,  chloroform,  etc., 
and  continuous  heat  by  the  warm  coil,  are  each  of  more  or  less 
service  in  mitigating  agony.  Lozenges  of  cocaine,  morphia,  etc., 
are  not  of  much  use  in  laryngeal  disease ;  but  sedative  inhalations 
of  benzoin,  chloroform,  conium,  etc.,  give  occasional  relief  to  the 
inflammation  (Form.  29,  30,  and  34) ;  detergent  and  antiseptic 
gargles,  especially  when  used  by  the  Von  Troeltsch  method 
(p.  102),  tend  to  diminish  the  annoyance  of  excessive  salivation, 
and  to  sweeten  the  sense  of  taste  and  the  odour  of  the  breath. 
Ear-drops  of  laudanum  and  belladonna  are  of  great  value  in 
diminishing  the  constant  and  wearying  ear-ache. 

One  practical  point  which  should  never  escape  the  notice  of 
the  surgeon,  in  the  treatment  of  these  cases,  is  reserved  for  the 
conclusion  of  this  section,  namely,  the  possibility  that,  in  spite  of 
apparently  decided  symptoms,  both  functional  and  physical,  the 
disease  may  be  due  to  the  syphilitic  dyscrasia ;  and  it  must  still 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


489 


further  be  remembered  that  the  one  does  not  necessarily  exclude 
the  other.  It  is  a  good  rule,  therefore,  to  give  antisyphilitic 
remedies,  especially  iodide  of  potassium,  or  preferably  of  sodium, 
at  the  commencement  of  the  treatment ;  care  being  taken,  how- 
ever, lest  the  error  be  made  of  mistaking  the  improvement,  w^hich 
so  often  occurs  in  the  first  few  weeks  of  such  a  course,  for  a 
prognostication  of  cure. 

2.  Surgical  measures  include — (A)  endo-laryngeal  attempts  at 
removal ;  (B)  endo-laryngeal  cauterizations  ;  (C)  tracheotomy  ; 
(D)  complete  extirpation ;  and  (E)  partial  extirpation  or  re- 
section. 

Consideration  of  the  advisability  of  operative  procedures  is 
always  sure  to  be  pressed  upon  the  notice  of  the  surgeon,  since 
both  the  patient  and  friends  are  naturally  anxious  that  the 
obstruction  to  deglutition  should  be  rem.oved,  and  that  the  hfe- 
threatening  dyspnoea  should  be  relieved.  There  can  be  no  objec- 
tion to  operative  measures,  provided  it  be  well  understood  on 
both  sides  that  the  relief,  though  it  may  be  considerable,  is  in  all 
probability  but  temporary,  and  that  the  inevitable  termination 
will  only  be  postponed. 

The  degree  of  danger  involved,  as  well  as  the  amount  of  benefit 
to  be  expected  from  the  various  operations  just  mentioned,  will 
now  be  considered  separately. 

A.  Possessed  of  a  strong  conviction  that  malignancy  may  be 
engendered  by  repeated  removals  of  a  (microscopically)  benign 
growth  manifesting  rapid  recurrence,  I  cannot  counsel  endo- 
laryngeal  attempts  at  removal  of  either  a  sarcomatous  or  an 
epitheliomatous  neoplasm,  the  pathological  nature  of  which  has 
been  demonstrated  by  competent  examination  of  a  portion  ex- 
perimentally detached.  Looking  to  the  natural  history  of  a 
sarcoma,  and  the  decidedly  unsatisfactory  nature  of  results  to 
eradicate  it  by  operation  from  such  easily  accessible  situations  as 
the  tonsil,  it  is  not  probable  that  any  procedure  of  the  same 
nature  lower  down  in  the  throat  would  be  of  permanently  good 
effect ;  and  the  same  objection  obtains  wdth  even  greater  force  in 
the  case  of  epithelioma.  I  concur,  therefore,  in  the  general  scep- 
ticism with  which  reports  of  '  cures  '  resulting  from  endo-laryngeal 
operations  for  malignant  disease  are  to  be  regarded.  An  exception 
must,  however,  be  made  in  favour  of  the  brilliant  success  which 
has  rewarded  the  skill  and  perseverance  of  ^"B.  Fraenkel  in  the 
following  case  : 

The  patient,  70  years  of  age,  had  a  tumour  on  the  right  vocal  cord  of  the  size  of  a  bean. 
This  was  extirpated  by  the  cautery  loop.    Microscoincally  it  proved  to  be  a  carcinoma. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


A  year  later  it  recurred,  and  was  again  extirpated.  During  the  next  three  years  there 
were  three  recurrences,  with  extirpation  after  each.  A  carcinomatous  gland  of  the  neck 
was  also  removed  by  Professor  Madelung.  The  patient  is  now  75  years  of  age,  and  for 
two  years  the  larynx  has  shown  no  sign  of  any  neoplasm.    The  voice  is  clear  and  loud. 

Such  a  case  is  indeed  a  triumph  of  intra-laryngeal  surgery,  and 
proud  would  any  surgeon  be  if  such  a  result  were  to  fall  to  his  lot. 
We  would  all  fain  hope,  but  can  hardly  expect,  that  this  case  will 
ever  be  otherwise  than  unique,  or  at  most  of  very  exceptional 
rarity. 

B.  The  case  just  reported  might  be  considered  as  included  in 
the  category  of  an  endo-laryngeal  cauterization,  but  this  term 
I  preferably  reserve  for  applications  of  the  galvano-cautery  to 
malignant  ulcerations  and  infiltrations  which  do  not  admit  of 
extirpation.  Such  a  procedure  has  twice  been  adopted  with  ad- 
vantage by  me,  once  in  an  epitheliomatous  ulcer  of  the  epiglottis, 
and  once  in  a  sarcoma,  extending  to  the  same  region  from  the 
tonsil;  but  my  experience  leads  me  to  fear  that  the  benefit  of  such 
a  measure  is  but  temporary.  With  regard  to  its  adoption  for  laryn- 
geal disease  at  a  lower  level,  I  may  once  again  quote  the  conclud- 
ing remarks  of  my  paper  at  the  International  Congress  of  1881 : 

'  While  without  the  galvano-cautery  in  diseases  of  the  nose,  pharynx,  mouth,  and 
tongue,  I  should  feel  deprived  of  at  least  one-half  my  power  to  help  the  conditions  for 
which  I  use  it,  I  have  a  strong  conviction  that  were  I  to  employ  it  to  such  regions  as  the 
larynx  below  the  epiglottis,  to  the  pharynx  below  the  sam.e  level,  or  to  the  oesophagus,  I 
should  introduce  into  my  practice  a  new  and  grave  element  of  danger.' 

The  employment  of  any  other  form  of  caustic,  as  the  traditional 
nitrate  of  silver,  is  futile ;  while  those  of  a  more  active  character, 
as  chromic  acid,  or  acid  nitrate  of  mercury,  are  attended  by  risks 
out  of  all  proportion  to  any  possible  chance  of  benefit. 

Electrolysis,  in  the  author's  hands,  has  given  such  favourable 
evidence  of  its  solvent  powers  in  cases  of  mesoblastic  growths 
in  the  palate  and  fauces  that  it  is  worthy  of  more  extended  trial 
in  the  larynx,  though  probably  the  cases  suitable  for  its  applica- 
tion will  always  be  restricted  in  number.  It  must  not,  however, 
be  forgotten  that  this  measure  is  strongly  contra- indicated  in 
epitheliomata,  in  which  the  effect  would  be  to  only  aggravate  the 
intensity  of  the  disease. 

C.  The  operation  of  tracheotomy  is  attended  with  very  con- 
siderable prolongation  of  life,  but  it  is  of  course  only  provisional 
against  dyspnoea,  and  palliative  of  the  same  vitally  serious 
symptom.  Fauvel's  statistics  from  his  own  experience  of  this 
operation  are  very  valuable ;  they  show  that  in  the  most  frequent 
form  of  malignant  disease — epithelioma — the  average  duration  of 
life  of  seven  patients  on  whom  tracheotomy  was  performed  was 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


491 


four  years ;  whereas  sf;^  patients  suffering  from  the  same  disease, 
who  were  not  submitted  to  this  operation,  Hved  only  on  an  average 
twenty -one  months.  Eight  tracheotomized  patients,  suffering  from 
encephaloid  cancer  (?  sarcoma)  of  the  larynx,  lived  an  average  of 
three  years  and  nine  months ;  while  seven,  not  tracheotomized,  sur- 
vived on  an  average  three  years.  Looking  at  the  fact,  that  by  such 
sn  operation  the  vital  symptom  of  dyspnoea  is  relieved,  and  that 
further  measures  by  galvano-cautery,  etc.,  are  rendered  more  easy 
and  more  safe,  these  figures  may  be  taken  as  demonstrating,  in 
the  words  of  Fauvel,  '  the  utility,  not  to  say  the  necessity,  of  this 
operation.''  In  one  case  of  intrinsic  epithelioma — diagnosed  by 
microscopical  examination — under  the  care  of  my  colleague, 
Dundas  Grant,  the  patient  lived  for  nearly  three  years  in  greatly 
increased  comfort.  For  some  months  after  the  operation  she 
even  gained  in  weight.   Such  an  experience  is  by  no  means  unique. 

An  important  element  in  considering  the  question  of  any  opera- 
tion on  the  larynx  for  malignant  disease  is  the  determination,  as 
far  as  possible,  whether  we  have  to  deal  with  an  epithelioma — 
cancer  in  fact — or  with  a  sarcoma.  Cancerous  growth,  if  it  can 
be  called  growth — perhaps  it  would  be  better  to  say  the  cancerous 
process — has,  within  each  of  its  constituent  elements,  intrinsic 
decay,  which  commences  almost  from  the  date  of  its  birth.  A 
sarcoma,  on  the  other  hand,  represents  an  unlimited  repetition  of 
cell-growth,  which  decays  by  the  ordinary  process  of  inflamma- 
tion ;  in  other  words,  either  from  extrinsic  irritation,  or  from  the 
new  growth  increasing  beyond  the  power  of  the  vascular  and 
nervous  supply  tg  sustain  living. 

In  a  case,  therefore,  of  supposed  malignant  disease  of  the  larynx, 
and  especially  if  the  respiratory  mechanism  be  impaired,  no  good 
purpose  is  subserved  by  delay,  for  supposing  even  that  the  diag- 
nosis should  haply  have  been  made  of  a  graver  malady  than  the 
after-history  confirms,  and  the  cannula  may  in  time  be  even  dis- 
pensed with,  not  only  would  no  harm  have  been  done,  but,  on  the 
contrary,  there  would  have  been  a  gain  to  the  patient,  if  only  in 
the  saving  of  the  muscular  force  wasted  absolutely  in  dyspnoeic 
breathing.  This  is  a  consideration  but  too  often  neglected, 
except  in  the  case  of  paralyses,  in  which  it  forms,  according  to  all 
writers,  the  chief,  and  sometimes  an  exceptional,  argument  in 
favour  of  an  early  tracheotomy. 

In  view  of  the  possibility  of  extension  of  the  disease,  trache- 
otomy, unless  made  as  a  preliminary  to  more  radical  measures, 
should  be  performed  as  low  as  possible  in  the  windpipe ;  for 
Cohen  reports  that  '  the  recurring  growth  may  force  its  way  to 


DJSEASES  OF  THE  THROAT  AND  NOSE. 


the  exterior  through  the  wound,  or,  as  he  had  seen  after  low 
tracheotomy,  it  may  rupture  an  intact  crico-thyroid  membrane, 
and  split  the  thyroid  cartilage  to  give  exit  to  its  out- growths.' 
In  tracheotomy  as  a  preliminary  to  extirpation,  the  high  opera- 
tion in  the  second  or  third  rings  is  preferable. 

D.  The  operation  of  complete  extirpation  of  the  larynx,  though 
not  for  carcinoma,  was  performed  by  ^^Patrick  Heron  Watson, 
of  Edinburgh,  so  far  back  as  1866,  and  was  not  repeated  till  1873, 
when  ^^Billroth  adopted  the  same  measure  for  the  disease  under 
present  consideration.    This  patient  died  from  recurrence  seven 
months  later.    Five  cases  followed,  one  of  which  was  again  under 
20Watson ;   one   (^^Heine)  terminated  with  recurrence  in  six 
months,  and  all  the  others  in  a  few  days.    Then  came  the  cele- 
brated case  of  22Bottini,  who,  in  1875,  removed  the  entire  larynx 
on  account  of  a  mix-celled  sarcoma.    The  patient  was  alive  ten 
years  after  the  operation,  and  pursuing  his  occupation.  Since 
then  the  operation  has  been  frequently  performed,  and  there  are 
now  fully  one  hundred  recorded  cases,  the  statistics  of  which 
have  been  frequently  detailed.    No  one  has  taken  such  pains  to 
investigate  the  subject  with  the  thoroughness  and  completeness 
of  ^2  Cohen,  and  I  am  much  indebted  to  his  latest  tables  for 
valuable  and  recent  information. 

'  From  the  records  referred  to,  and  from  study  of  some  of  the  reports  in  detail,  it 
appears  evident  that  complete  laryngectomy  can  be  performed  without  sacrifice  to  life, 
but  that  every  operation  places  life  in  peril ;  and  that  a  large  number  of  the  patients 
succumb  within  a  period  so  brief,  that  their  early  death  is  attributable  to  the  operation, 
and  to  nothing  else.  Of  the  deaths  reported  (to  May,  1884,  ninety-one  in  all),  twenty- 
six  occurred  within  the  first  eight  days,  and  five  more  within  the  second  eight  days — more 
than  one-third  of  all  the  patients  subjected  to  laryngectomy  having  thus  succumbed  within 
little  more  than  a  fortnight.  The  most  usual  cause  of  death  in  this  period  is  from  pneu- 
monia, and  the  period  of  danger  from  this  event  does  not  seem  to  exceed  two  weeks, 
unless  the  conditions  are  exceptional.  This  important  fortnight  of  tribulation  safely 
bridged,  the  life  of  the  patient  may  be  regarded  as  tolerably  secure  up  to  the  fourth 
month.  Then  death  from  recurrence  begins  to  be  imminent,  and,  according  to  circum- 
stances, will  take  place  within  an  additional  period  varying  from  a  few  weeks  to  several 
months,  or  to  more  than  a  year.  Complete  laryngectomy  involves  great  risk  of  death  by 
pneumonia,  future  respiration  through  an  artificial  aperture,  temporary  nourishment  by 
the  stomach-tube,  and  possibly  utter  inability  to  speak  vdthout  the  aid  of  an  artificial 
substitute  for  the  larynx,  adjusted  to  the  tracheal  canula.' 

I  have  preferred  to  quote  Cohen's  conclusions  in  place  of  any  of 
my  own,  albeit  they  are  identically  to  the  same  effect  and  of  long 
formation,  because  my  well-known  views  as  to  undue  rashness  in 
endo-laryngeal  operations  might  be  held  to  prejudice  my  opinions 
on  this  question  also.  When,  eight  years  ago,  the  late  Dr.  Foulis, 
of  Glasgow,  showed  at  the  Medical  Society  the  patient  from  whom 
he  had  successfully  extirpated  the  whole  larynx  four  months  pre- 
viously, for  '  papilloma  and  spindle-celled  sarcoma,'  I  ventured  to 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX.  493 

express  a  doubt  whether  that  operation  would  ever  yield  benericial 
results  commensurable  with  the  immediate  danger  of  its  perform- 
ance, the  very  short  extension  of  life,  and  the  discomfort  of  an 
artificial  larynx  to  those  who  survived  long  enough  to  wear  one ; 
and  I  drew  attention  to  the  superiority  of  the  statistics  of  tracheo- 
tomy to  those  of  the  radical  operation.  Dr.  Foulis's  was  the 
eighteenth  complete  extirpation,  and  the  second  which  survived 
more  than  nine  months,  for  his  patient  lived  a  year  and  a  half, 
and  death  ultimately  resulted  from  phthisis. 

For  the  honour  of  British  surgery  it  is  gratifying  to  be  enabled 
to  state  that  not  only  was  this  courageous  procedure  first  adopted 
by  a  British  surgeon,  as  already  recorded,  but  that  generally  the 
success  in  this  country  has  been  equal  to  that  of  Continental,  and 
especially  of  German  operators.  Thus  ^^poulis  operated  on  a 
second  patient  in  April,  1881,  who  survived  nine  months.  In  the 
case  of  a  patient  operated  on  by  Whitehead,  of  Manchester,  in 
May,  1882,  that  surgeon  reports  to  me  that  he  lost  sight  of  his 
patient,  but  that  he  was  well  twelve  months  afterwards.  Jones, 
of  the  same  city,  had  a  case  in  April,  1884,  which  he  informs  me 
survived  nine  months;  and  Newman,  of  Glasgow,  successfully 
removed  the  larynx  on  February  6,  1886,  from  a  man  aged  thirty- 
seven,  who  in  March,  1887,  thirteen  months  after,  is  well,  and 
*  able  to  follow  his  occupation.' 

On  the  other  hand,  the  operation  has  been  performed  in  this 
country,  as  on  the  Continent,  somewhat  unjustifiably,  for  cica- 
tricial stenoses  and  for  benign  formations,  and  also  under  very 
adverse  circumstances — namely,  without  requisite  precaution,  in 
the  shape  of  a  proper  tampon-canula,  against  introduction  of 
blood  into  the  trachea,  and  even  without  a  preliminary  trache- 
otomy. It  has  also  been  performed  on  more  than  one  occasion, 
as  recently  by  Henry  Morris,  in  response  to  urgent  request  of 
the  patient,  without  regard  to  any  abstract  question  of  favourable 
statistics.  But,  however  all  these  points  may  be  viewed,  the 
general  results  are  so  discouraging  that  many  surgeons  who  have 
performed  the  operation  have  resolved  never  to  repeat  it,  while 
others  have  adopted  measures  less  hazardous. 

E.  Of  these  less  dangerous  operations,  partial  laryngectomy, 
in  the  form  of  removing  a  lateral  half,  stands  in  the  first  rank. 
The  risk  of  pneumonia  is  less,  exposure  of  the  pneumogastric 
being  confined  to  only  one  side  instead  of  both  ;  if  the  raspatory 
be  used  for  the  removal  of  soft  parts,  as  in  my  practice,  the  nerve 
need  not  be  exposed  at  all.  The  danger  of  pneumonia  in  its 
septicsemic  form,  as  a  result  of  blood  entering  the  lower  air- 
passages,  has  been  still  further  lessened  by  introduction  of  the 
compressed  sponge  tampon-canula,  which  is  an  immense  advance 


494 


DISEASES  OF  THE  THROAT  AND  NOSE. 


on  the  indiarubber  inflating  tampon-canula  of  Trendelenburg. 
For  this  improvement — as  also,  indeed,  for  general  acceptance  of 
the  operation — the  profession  is  indebted  to  Eugene  Hahn,  who 
had  already  great  success  with  complete  extirpation,  and  has 
since  recorded  several  instances  of  partial  removal  with  equally 
happy  results.  There  are  now  recorded  some  thirteen  or  fourteen 
cases,  and  in  only  one  instance  has  there  been  an  immediately 
fatal  result.  The  operation  possesses  the  following  additional 
advantages  :  deglutition  is  not  impaired,  an  artificial  larynx  is  not 
required — nor  even,  after  a  few  days,  a  tracheotomy  tube — and 
a  very  fair  and  serviceable  voice  is  generally  restored. 

Recurrence  must,  in  the  nature  of  things,  be  always  anticipated; 
and  we  have  yet  to  see  what  sort  of  history  cases  will  have  in  this 
respect.  So  far  there  is  reason  to  expect  that  the  operation  may 
afford  average  periods  of  immunity  from  recurrence  even  of  the 
more  serious  forms  of  malignant  disease  almost,  if  not  quite,  equal 
to  those  provided  by  tracheotomy.  It  is  earnestly  to  be  hoped 
that  care  will  be  taken  in  the  selection  of  subjects  for  this  opera- 
tion, as  otherwise  discouragement  will  be  given  to  its  performance 
where  other  circumstances  w^ould  be  favourable. 

Partial  laryngectomy  has  been  advised  for  unilateral  and  intra- 
laryngeal  epithelioma,  and  in  recent  non-infiltrating  sarcoma.  It 
is  useless  in  pharyngo-laryngeal  epithelioma,  in  which  the  larynx 
is  invaded  from  the  pharynx,  and  whenever  there  is  implication 
of  the  cervical  glands  and  structures  adjoining  the  larynx.  It  is 
always  possible,  if  on  division  of  the  thyroid  cartilage  the  disease 
is  seen  to  have  extended  beyond  the  limits  suspected  by  prior 
examination,  for  the  surgeon  to  desist  from  removal,  and  to  be 
content  with  having  performed  a  palliative  tracheotomy. 

This  question — whether  intra-laryngeal  cancer  can  be  best 
treated  by  a  palliative  tracheotomy  or  by  attempts  at  radical 
extirpation — is  still  suh  judice.  To  arrive  at  a  fair  verdict  every 
case  of  laryngectomy  and  thyrotomy  should  be  fully  recorded. 

A  case  in  my  own  practice  has  already  been  published  at  a 
period  long  prior  to  the  time  at  which  the  real  issue — that  of 
immunity  from  recurrence — can  be  settled,  because  I  believe  that 
the  difficulties  of  the  operation,  and  also  its  immediate  dangers, 
have  been  largely  exaggerated. 

I  may  just  say  that  the  special  dangers  to  which  I  allude  are 
those  of  haemorrhage  and  of  secondary  pneumonia.  The  abridged 
account  of  the  case  which  now  follows  points  out  in  the  most 
practical  way  the  various  steps  of  the  operation,  and  the  special 
precaution  I  adopted  to  avoid  haemorrhage — the  fear  of  which  has 
been  so  great  that  in  one  case  (of  complete  extirpation)  Langen- 
beck  was  obliged  tc  tie  forty  arteries. 


MALIGNANT  N^OPLASMiS  OF  THE  LARYNX. 


495 


Case  ii.  — G.  W.,  aged  6i,  occupied  in  a  limber-yard,  applied  at  the  hospital  as  an 
out-patient,  on  November  l,  1886,  on  account  of  hoarseness  of  voice,  and  occasional 
tickling  cough,  first  noticed  about  two  years  ago  ;  he  had  never  suffered  pain,  or  anything 
approaching  inconvenience  in  breathing,  except  when  hurrying  to  catch  a  train  or  omnibus. 

The  patient  was  a  hale-looking  man  for  his  age,  5  feet  6  inches  in  height,  and  weigh- 
ing 166  lb.     The  laryngoscope  showed  that  while  both  vocal  cords  were  congested, 


the  left  cord  was  immobile  and  ulcerated  at  its  pos- 
terior portion.  There  was  at  that  time  but  little 
thickening  of  the  left  ventricular  band,  and  of  the 
tissues  of  the  left  laryngeal  boundary  of  the  pharynx, 
as  is  seen  by  reference  to  Fig.  CXC,  which  was 
drawn  six  weeks  after  his  first  applying  at  the  hospital. 
There  was  neither  then,  nor  indeed  at  any  period,  in- 
volvement of  the  cervical  glands,  nor  was  there  any 
constitutional  symptom  pointmg  to  malignity.  Anti- 
syphilitic  treatment  pursued  for  six  weeks  failed  to 
arrest  the  ulceration,  and  there  was  decided  diminu- 


tion in  weight ;  for  on  December  13  he  weighed  only  y\g.  CXC— Laryngoscopic  Ap- 
160  lb.,  a  loss  of  6  lb.  in  six  weeks.  It  was  therefore  pearance  prior  to  Operation. 
decided,  after  consultation  with  my  colleagues,  to 

attempt  removal  of  the  diseased  half  of  the  larynx,  and  the  patient  being  admitted  to  the 
hospital  December  I3ih,  the  operation  was  performed  on  the  15th. 

The  operation,  which  lasted  an  hour  and  a  half  in  all,  may  be  conveniently  divided  into 
four  stages  : 

1.  A  high  tracheotomy  between  the  second  and  third  rings,  and  the  introduction  of 
Hahn's  tampon-canula,  consisting  of  a  tube  surrounded  by  compressed  sponge.  This 
was  first  dipped  in  a  solution  of  corrosive  sublimate  (i  in  5,000). 

2.  An  interval  of  twenty  minutes  for  expansion  of  the  tampon  ;  anaesthesia  being 
maintained  by  the  administration  of  chloroform  through  the  tracheal  tube. 

3.  Thyrotojny. — The  median  incision  was  extended  from  just  above  the  tracheal 
opening  to  the  lower  margin  of  the  hyoid  bone,  and  all  the  tissues  were  carefully  divided 
on  a  director  until  the  thyroid  cartilage  was  reached.  The  soft  parts  over  the  thyroid  and 
cricoid  cartilages  were  rasped  sub-perichondrially,  the  raspatory  being  kept  so  close  that 
the  perichondrium  was  literally  peeled  away  from  the  cartilage,  whilst  its  relation  to  the 
superficial  soft  parts  remained  undisturbed.  The  separation  w^as  carried  back  by  this 
means  as  far  as  the  median  line  of  the  boundary  between  the  larynx  and  pharynx ;  no 
scissors,  knife,  or  other  instrument  than  the  raspatory  was  used.  A  horizontal  incision 
over  the  hyoid  bone,  as  recommended  by  Hahn,  was  not  necessary,  the  vertical  one 
proving  amply  sufficient,  but  part  of  the  hyoid  attachment  of  the  thyro  hyoid  muscle  was 
severed.  The  much  ossified  tliyroid  cartilage  was  then  divided  bv  cutting  forceps  along  its 
centre  ;  the  wings  were  separated  by  retractors,  and  the  growth  was  seen  to  be  confined 
entirely  to  the  left  half  of  the  larynx,  which  portion  it  was  decided  to  remove. 

4.  Laryngedoniy  was  efifected  by  {a)  further  careful  and  thorough  separation  of  the 
attachments  to  the  pharynx  by  raspatory,  knife-handle,  and  finger-nail ;  {b)  division  ol 
the  thyro-hyoid  membrane,  as  close  as  possible  to  its  thyroid  attachment ;  (<r)  division  of 
the  left  superior  horn  of  the  thyroid  cartilage  at  its  root  by  cutting  pliers  ;  {d)  division  in 
the  median  line  of  the  cricoid  cartilage,  before  and  behind,  with  pliers  ;  {e)  the  divided 
half  of  the  larynx  was  then  separated  from  the  first  ring  of  the  trachea,  and  a  few  nicks 
only  were  necessary  to  remove  it  entire. 

The  following  points  regarding  the  operation  are  worthy  of  note.  Haemorrhage,  the 
extent  of  which  is  usually  described  as  serious,  was,  in  point  of  fact,  quite  trifling ;  only 
two  small  vessels  required  torsion  in  the  second  stage  of  the  operation.  Not  only  were 
no  vessels  searched  for,  as  recommended  by  most  writers,  but  none  of  any  size  were 


496 


DISEASES  OF  THE  THROAT  AND  NOSE. 


exposed,  this  hnppy  circumstance  being  doubtless  due  to  the  use  of  the  raspatory  in 
preference  to  scalpel  or  scissors,  and  also  to  keeping  so  close  to  the  cartilage.  The  soft 
parts  were  little  disturbed  in  consequence.    I  am  indebted  to  Mr.  Henry  Morris  for  the 

hint  to  adopt  this  procedure,  and  to  it  I  attribute 
a  very  large  measure  of  the  success  of  the  operation 
in  its  immediate  and  subsequent  circumstances.  The 
slight  oozing  which  ensued  after  the  removal  of  the 
diseased  portion  of  the  larynx  was  checked  by  a 
light  application  of  the  galvano-cautery  along  the 
margin  of  division.  This  procedure  was  also  adopted 
for  the  purpose  of  destroying  any  possible  fragments 
of  diseased  tissue  not  removed.  The  left  ary-epiglottic 
fold  was  divided  close  to  the  cartilage  of  Wrisberg, 

^  and  the  thyro-hyoid  membrane  close  to  its  thyroid 

I'lG.   CXCI.— Laryngoscopic  ,  .  ,    ,      .       ,  .      .  .         ,-  , 

View  Sixteen  Wkeks  after  attachment,  with  the  view  of  impairing  as  little  as 
Operation.    (April  5,  1887.)     possible  the  action  of  the  epiglottis.    The  success 

of  this  plan  was  completely  shown  in  the  ease  with 
which  deglutition  was  effected  three  days  later.  No  spray  was  used  ;  but  antiseptic 
precautions  were  adopted  by  the  operator,  assistants,  and  nurses  first  bathing  their  hands 
in  a  solution  of  the  perchloride  of  mercury  (i  in  5,000),  and  by  the  cleansing  and  rinsing 
of  all  instruments  and  sponges  in  a  similar  preparation. 

The  patient  made  an  excellent  recovery,  and  but  with  one  relapse  of  a  few  days,  due  to 
carelessness  of  the  nurse.  He  was  fed  with  a  tube  for  the  first  three  days,  but  seventy-eight 
hours  after  the  operation  the  patient  was  ordered  a  mutton  chop  to  eat,  according  to  the 
treatment  of  Hahn,  who,  for  obvious  reasons,  recommends  solid  food  as  the  first  to  be 
given  by  the  mouth.  On  Christmas  Day,  the  eleventh  from  the  operation,  he  had  turkey 
and  champagne  for  dinner,  and  from  that  date  convalescence  was  uninterrupted.  He 
'got  up'  for  the  first  time  on  the  seventeenth  day  after  operation.  The  tracheal  tube 
was  removed  on  the  twentieth  day,  that  is,  on  January  3rd.  His  weight  was  then 
148  lb.,  being  a  loss  of  12  lb.  since  the  operation. 

April  5th,  that  is,  the  1 12th  day,  wound  is  healed  and  the  patient  speaks  with  a  wonder- 
fully good  though  rough  voice  ;  it  is  distinctly  phonetic,  and  he  thinks  it  is  '  at  least  as 
good  as  before  the  operation.'  His  strength  and  general  health  have  been  well  main- 
tained, and  he  looks  and  feels  well.  His  weight  has  not  changed  since  January  3rd.  The 
laryngoscopic  appearance  at  this  date  is  represented  in  Fig.  CXCI.  The  right  vocal 
cord  moves  freely,  but  is  still  somewhat  congested ;  the  structures  on  the  left  side  of  the 
glottis  move  slightly  towards  the  median  line  in  phonation  ;  the  epiglottis  acts  perfectly, 
and  is  not  in  the  least  out  of  position. 

Examination  of  the  growth,  after  removal  (Fig.  CXCH.,  and  Plate  XIV.,  Fig.  121), 
showed  it  to  have  sprung  from  the  ventricle,  and  not  from  the  vocal  cord,  as  had  been 
diagnosed  on  laryngoscopic  examination,  in  this  respect  resembling,  both  in  its  site  and 
P.S.  :  1889.— The  patient  survived  thirteeen  months,  and  died  of  a  recurrence  which 
necessitated  a  second  tracheotomy. 

Examination  of  the  growth,  after  removal  (Fig.  CXCH.,  and  Plate  XIV.,  Fig.  121), 
showed  it  to  have  sprung  from  the  ventricle,  and  not  from  the  vocal  cord,  as  had  been 
diagnosed  on  laryngoscopic  examination,  in  this  respect  resembling,  both  in  its  site  and 
in  the  misconception,  several  cases  reported  by  other  surgeons.  The  extent  of  the  disease 
was  so  far  greater  than  had  been  suspected  prior  to  operation  ;  this  circumstance  of  the 
case  illustrates  the  very  foreshortened  view,  with  consequently  incomplete  diagnosis,  which 
may  sometimes  be  obtained  by  looking  into  the  larynx  from  above.  Generally,  the  naked- 
eye  evidences  were  those  of  epithelioma. 

The  structure  of  a  superficial  unstained  shaving  (Fig.  CXCIII.),  removed  for  diagnostic 
purposes,  presented  the  appearance  of  a  typical  squamous  epithelioma,  the  nests  being 
remarkably  abundant.  A  later-stained  and  hardened  section  was  made  of  a  portion  of 
the  tumour  removed  much  deeper.    This  was  seen,  under  the  microscope,  to  consist  of  a 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX.  497 


dense  connective-tissue  stroma,  with  great  increase  of  nuclei  and  cellulnr  infiltration,  and 
of  a  large  number  of  solid  columns  of  an  epitheliomatous  character,  the  outermost  laye.r 
of  cells  being  composed  of  the  columnar  variety,  enclosing  a  core  of  polygonal  cells. 
This  condition  is  shown  in  Fig.  CXCIV.    Only  one  or  two  distinctly  squamous  nests  v/ere 


Fig.  CXCII.— Internal  Aspect  of  Removed  Portion  (Life-size). 
A,  Spot  whence  portion  was  removed  for  microscopical  examinauon. 

observed  near  the  surface.  The  bulk  of  the  growth  was,  therefore,  an  epithelioma  of  the 
columnar-celled  variety,  with  squamous  characters  predominating  near  the  surface.  Taking 
into  account  the  fact  that  the  ventricle  of  the  larynx  is  lined  with  columnar  epithelium,  it 
is  not  to  be  wondered  that  the  growth  exhibited  these  characters.    In  shavings  taken  from 


Fig.  CXCIIL— Microscopical     Fig.    CXCIV  — Microscopic    Appearance  op 
Appearance  of  Superficial  Growth  from  Deeper  Section. 

Section  of  Growth. 

{From  drawings  by  Mr.  G.  W.  Hill,  Pathologist  of  the  Hospital. ) 


the  extreme  edge  of  the  portion  of  the  larynx  removed,  neither  nests  nor  columns  could 
be  detected  ;  and  the  same  satisfactory  negative  evidence  was  afforded  by  repeated  micro- 
•scopic  examination  of  two  fragments,  removed  for  that  purpose  at  the  time  of  operation, 
from  the  margin  of  the  structures  left  behind. 


Thyrotomy,  or  division  of  the  thyroid  cartilages  and  removal  of 
the  diseased  portion,  leaving  the  cartilages  intact,  has  been 

32 


498 


DISEASES  OF  THE  THROAT  AND  NOSE. 


thought  to  be  attended  with  immediate  risk  fully  equal  to  that 
of  unilateral  excision,  and  to  be  withal  too  incomplete  to  take  rank 
as  a  legitimate  operation.  Indeed,  the  unfavourable  summary  of 
its  results  by  ^^Bruns  caused  this  procedure  for  cancer  to  be 
almost  abandoned  in  favour  of  laryngectomy.  But  a  decided 
reaction  has  recently  taken  place.  It  is  doubtful  whether  laryn- 
gectomy is  ever  successful  in  prolonging  life  for  a  longer  period 
than  a  simple  tracheotomy,  or  of  giving  immunity  against  recur- 
rence (there  are  but  two  or  three  recorded  instances  in  which 
patients  have  lived  over  two  years),  except  in  those  cases  in  which 
intrinsic  mahgnant  disease,  not  extending  to  the  pharynx,  has 
been  recognised  before  it  has  attacked  the  cartilaginous  frame- 
work or  invaded  the  glands.  In  such  cases  ^^Butlin  has  proposed, 
and  has  successfully  performed,  thyrotomy  and  erasion  of  all  the 
soft  tissues,  including  the  growth  of  the  affected  side.  This  is 
probably  the  radical  operation  of  the  immediate  future,  and  at- 
tempts at  such  will,  it  is  hoped,  be  limited  to  this  measure  and 
to  that  class  of  cases  for  which  it  is  indicated. 

Sublingual  pharyngotomy,  which  consists  in  division  of  the 
thyro-hyoid  membrane  and  removal  of  the  growth  through  the 
opening  thus  made,  is  only  applicable  to  disease  of  the'  epiglottis, 
and  is  also  a  procedure  of  very  limited  and  doubtful  value. 

3.  Hygienic  and  dietetic  treatment  in  the  case  of  laryngeal 
cancer  may  be  comprised  in  few  words.  Protection  against 
impurities  of  the  inspired  atmosphere  by  respirators,  and  resi- 
dence in  pure  air,  with  the  avoidance  of  tobacco^  and  of  ardent 
spirits,  as  well  as  of  any  habit  or  occupation  hkely  to  induce  local 
irritation,  are  to  be  enjoined.  So  soon  as  there  are  symptoms 
of  dysphagia,  instead  of  efforts  being  made  to  force  the  deglutition 
of  solids,  an  immediate  change  of  diet  should  be  advised,  and 
fluids  and  semi-solids,  or  at  least  artificially  masticated  and  pep- 
tonized foods,  should  be  prescribed.  In  some  instances  an 
occasional  rest  for  a  few  days  of  the  function  of  deglutition,  and 
limit  of  the  act  of  swallowing  to  only  sedative  and  thirst-allaying 
drinks,  with  administration  of  nutriment  per  rectum,  is  attended 
by  improvement  when  attempts  to  swallow  are  resumed.  Feed- 
ing by  an  oesophageal  tube,  except  temporarily  after  operations, 
is  a  somewhat  hazardous  process,  as  perforation  of  the  oesophagus 
may  thereby  be  unintentionally  induced.  Swallowing  of  the  raw 
egg  en  bloc  is  almost  always  possible,  and  the  recommendation  to 
suck  small  pieces  of  ice  is  a  measure  that  is  always  gratefully 
acknowledged  by  the  patient.  Applications  of  cocaine  prior  to 
food-taking  give  relief  in  some  cases,  but  this  is  a  matter  rather 
medical  than  hygienic  in  character. 


MALIGNANT  NEOPLASMS  OF  THE  LARYNX. 


REFERENCES  TO  AUTHORITIES. 


PAGE, 

NO. 

NAME. 

TITLE  OF  W^ORK   REFERRED  TO. 

467 

467 

468 

469 
469 

469 

470 

472 

476 

476 
476 
475 
476 
476 

477 
478 

489 

492 
492 
492 
492 
492 

492 

493 

493 

493 

493 

493 
494 
494 
498 
498 

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2 

3 

4 
5 
6 

8 

9 
10 
II 
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13 
14 

15 
16 

17 

18 

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20 
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22 

23 
24 
25 
26 

27 

28 
29 
30 

3' 

32 

Fauvel. 
Krisharek, 

BUTLIN. 

MORELL-M  ACKENZ]  E. 

Semon. 
Sappey. 

Norton. 

Fagge. 

Sands. 

D ESN  OS. 

Schiffers. 
Zeissl. 

Von  Ziemssen. 
Lennox  Browne. 
Blanc. 

B.  Fraenkel. 

P.  H.  Watson. 

Billroth. 

P.  H.  Watson. 

Heine. 

Bottini. 

SoLis  Cohen. 

D.  FouLis. 

W.  Whitehead. 

Thomas  Jones. 

D.  Newman. 

H.  Morris. 
Hahn. 

Lennox  Browne. 

Bruns. 

Butlin. 

/  Traite  pratique  des  Maladies  dii  Laryiix, 
\    Paris,  1876. 

Gazette  Hehdovi.^  p.  518.  1879. 

{ iMali^uant  Disease  of  the  Larynx.  London, 

\  1883. 

Op.  cit.,  p.  36. 

Brit.  Med.  Journal,  vol.  i.,  p.  281.  1S80. 
i Anatoinie  Descriptive,  vol.  ii.,  p.  861. 
\    Paris,  1869. 

/  Vaisseanx  LympJiatiqiics  cJiez  l'Uo/n?;/e, 

\     etc.,  p.  107  ef  seq.    Paris,  1874  to  1885. 
Path.  Transactions,  xxiii.,  p.  43.  1S72. 

i  Principles  and  Practice  of  Medicine,  vol.  i., 
\    p.  825.    London,  1886. 
New  York  Med.  Jottrn.,  p.  iio.  1865. 
Bull.  Soc.  Anat.,  40  ser.,  iii.,  p.  398.  1878. 
A'evne  Mens,  de  LaryngoL,  p.  i.  1883. 

Wiener  Med.  Presse,  xxii.,  p.  1373.  1871. 

Handlnich,  Heft  I,  p.  405. 

J  Oihccniatonia,  or  the  Insane  Ear  ( West 

\    Riding  Asyli(7)i  A'eporls).  1876. 
Cancer  Primitif  dii  Larynx.    Paris,  1 872. 

TLangenbeck's  Archiv.f.  Clin.,  Bd.  xxxiv., 
\     Heft  2  ;  and  Joiii-n.  of  LaryngoL,  vol.  i., 

(     No.  2,  p.  67. 

f  Trans.  Internat.  Med.  Congress,  vol.  iii., 
\    p.  255.  1881. 

Archiv.p.  lUin.  Chirurg.,  Bd.  xvii.,  S.  343. 
/  Trans.  Internat.  Med.  Congress,  vol.  iii. , 
I    p.  255.  1881. 

Archiv.f.  Klin.  Chirurg.,  Bd.  xix.,  S.  584. 
f  Trans.   Royal  Acad.  Medicin.,  Torino, 
\    April  30,  1875. 

{Internal.  Cyclop.  Surgery,  vol.  v.,  p.  770. 
\    New  York,  1884. 

] Brit.  Med.  jfonrnal.  May  7,  1881  ;  and 
\    May  8,  1S86. 

\  Lancet,  p.  741,  Nov.  4,  1881  ;  and  com- 

munication  to  author,  Feb.  28,  1887. 
^Lancet,  p.  191,  Aug.  2.  1S84  ;  and  coni- 

munication  to  author,  Feb.  28,  1887. 
{Brit.  Med.  Journal,  p.  868,  May  8,  1886  ; 
\     and  communication  to  author,  P^eb.  28, 
[  1887. 

Trans.  Clin.  Society,  1886. 

/R.   Volknriann's    Sanwilung  Klinischer 

\     Vortrdge.    Leipzig,  1885. 

Brit.  Med.  Journal.    February  5,  1SS7. 

(Die  Laryngotoinie  zur  Entfernung  intra- 

\     laryne-ealar  Neul'ildungen.  Berlin,  187B. 

Trans.  Clinical  Society.  1889. 

CHAPTER  XXIir. 


NEUROSES  OF  THE  LARYNX. 

(Figs.  93  to  loo,  Plate  X.) 

The  neuroses  of  the  larynx  may  be  divided  into  two  classes, 
viz.,  those  affecting  sensation  and  those  affecting  muscular  move- 
ment. 

NEUROSES  OF  SENSATION. 

The  amount  of  sensibility,  or  rather  the  degree  of  forbearance 
of  the  larynx  to  the  stimulus  of  an  ordinary  examination,  and  to 
many  varieties  of  foreign  visitants,  varies  greatly  within  the  limits 
of  physiological  health. 

Anesthesia. — Diminished  sensibility  of  the  laryngeal  mucous 
membrane  is  likewise  a  symptom  of  several  diseases,  and  is 
present  in  a  large  majority  of  those  cases  in  which  there  is  im- 
pairment of  motor  power.  This  diminution  of  sensation  is 
without  doubt  due  to  peripheral  causes  in  diphtheria,  syphilis, 
and  in  some  cases  of  long-standing  chronic  inflammation,  and 
partially  in  those  rare  instances  in  which  the  patient  recovers 
from  attacks  of  typhus,  variola,  and  erysipelas,  which  have  been 
accompanied  by  severe  throat  complications. 

In  diphtheria,  as  we  know,  there  is  often  superadded  to  peri- 
pheral paralysis,  injury  to  the  medulla  ;  and  the  fact  that  even 
where  the  original  disease  has  been  almost  confined  to  the 
pharynx,  parts  supplied  by  the  inferior  laryngeal  nerve  have 
suffered,  would  indicate  that  in  these  cases  the  pneumogastric 
is  also  frequently  involved. 

In  hysteria  and  bulbar  paralysis  the  anaesthesia  is  probably 
central  in  its  origin. 

I  have  drawn  attention  to  pharyngeal  anaesthesia  (p.  222)  in 
the  general  paralysis  of  the  insane,  and  this  abnormal  condition 
is  also  to  be  observed  in  the  larynx.  ^  McBride  has  also  alluded 
to  hcmi-ancBstlmia  of  the  larynx,  as  a  result  of  tumours  of  the  base 


NEUROSES  OF  THE  LARYNX. 

of  the  skull ;  instances  of  this  condition  have  been  recorded  by 
Fraenkel,  Schech,  and  himself. 

Anaesthesia  of  the  larynx  has  been  noticed  as  being  exhibited 
in  a  marked  degree  in  cases  of  cholera  ;  but  it  is  indeed  common, 
in  the  last  hours  of  life,  to  many  diseases,  especially  those  in 
which  death  is  by  apnoea.  Local  anaesthesia  of  the  larynx  may 
be  induced  artificially  by  various  anodyne  applications,  chief  of 
which  is  cocaine. 

The  principal  symptom  is  want  of  reaction  to  the  presence  of 
food  or  other  foreign  body  in  the  larynx.  When  the  intruder 
reaches  the  trachea  violent  cough  is  induced,  and  even  more 
serious  effects  may  result.  Allusion  has  already  been  made  to  the 
fact  of  the  great  tolerance  with  which  an  hysterical  patient  will 
bear  laryngoscopic  examination  ;  and  this  paralysis  of  sensibility 
accounts  also  for  the  difficulty  of  stimulating  the  muscles  to  motor 
action  in  cases  of  functional  aphonia,  unless  a  powerful  current  be 
applied  directly  to  the  laryngeal  cavity.  ^Von  Ziemssen,  there- 
fore, has  used  the  electrical  current,  carefully  localized  in  its 
application,  as  a  means  of  diagnosis.  This  is  a  more  certain 
method  than  the  laryngeal  probe. 

In  anaesthesia,  the  epiglottis  is  generally  observed  with  the 
laryngoscope  to  stand  upright. 

The  PROGNOSIS  of  anaesthesia  after  diphtheria  (for  the  other 
varieties  do  not  call  for  further  mention)  is  favourable  even  in 
those  instances  in  which  there  continues  impairment  of  motor 
action. 

Treatment. — When  the  condition  is  clearly  traced  to  a  peri- 
pheral cause,  faradization  is  generally  all-sufficient ;  but  in  some 
instances  the  constant  current,  with  one  pole  applied  over  the 
larynx,  and  the  other  down  the  cervical  portion  of  the  spine,  is 
indicated.  Internally,  iron,  strychnine,  and  phosphorus  are  of 
use.  I  have  found  good  results  from  phosphide  of  zinc  given  in 
doses  of  one-third  of  a  grain.  In  those  cases  where  there  is 
paralysis  of  the  epiglottis  it  may  be  necessary  to  feed  the  patient 
with  an  oesophageal  tube.  Von  Ziemssen  seems  to  fear  the  false 
passage  of  such  a  tube  into  the  larynx.  If,  however,  the  index- 
finger  of  the  left  hand  of  the  operator  be  passed  far  back  to  the 
base  of  the  tongue,  and  the  tube  be  pressed  against  the  posterior 
wall  of  the  pharynx,  and  made  to  pass  behind  the  introduced 
finger,  no  difficulty  whatever  should  be  experienced. 

Hyperesthesia. — Increased  reflex  sensibility  varies  with  dif- 
ferent individuals  quite  independently  of  any  abnormal  condition, 
but  it  is  also  a  common  symptom  in  diseases  of  the  glandular 


502  DISEASES  OF  THE  THROAT  AND  NOSE. 

structure  of  the  larynx  and  pharynx,  as  distinguished  from  those 
diseases  which  may  attack  other  portions  of  the  submucosa. 

We  thus  find  it  in  chronic  pharyngitis  and  laryngitis,  and  in 
laryngeal  phthisis.  The  peculiar  loud,  barking  cough  of  nervous 
females  is  due  to  this  reflex  excitability.  It  has  been  suggested 
by  some  authors  that  this  hyper-sensitiveness  is  due  to  the  highly 
nervous  condition,  so  characteristic  and  easily  comprehended  a 
symptom  in  patients  suffering  from  chronic  pharyngitis,  w^hich 
may  be  denominated  '  speakers'  sore  throat.'  But  this  cannot  be 
allowed,  since  in  phthisis  patients  are  by  no  means  unduly 
nervous.  Seeing  also  that  the  same  symptom  is  very  common 
in  the  throat  inflammations  of  drunkards,  it  is  much  more 
probable  that  gastric  derangement,  associated  as  it  is  with  all  the 
diseases  mentioned,  is  the  cause  of  the  neurosal  excitability  ;  and 
in  proof  of  this  it  may  be  remarked  that  the  reflex  sensibility 
often  continues  after  the  local  catarrhal  disease  has  been  cured. 

With  this  condition  are  often  associated  many  painful  sensa- 
tions, which  have  been  alluded  to  under  the  headings  of  the 
different  diseases. 

Paresthesia  of  the  larynx  is  almost  always  to  be  accounted 
for  by  a  disorder  of  the  venous  circulation,  either  local  or  general, 
as  has  been  explained  in  my  remarks  on  a  similar  condition  of  the 
pharynx  (p.  223).  To  dismiss  these  cases  as  hysterical  is  not 
only  unfair  to  the  patient,  but  very  unsatisfactory.  It  is  perhaps 
a  strong  thing  to  say,  but  it  is  almost  completely  true,  that  the 
word  '  hysteria  '  has  much  to  answer  for  in  the  fact  that  it  has 
greatly  retarded  our  knowledge  of  nervous  disorders.  But  too 
frequently  the  diagnosis  *  hysterical '  does  but  express  an  inability 
to  account  for  symptoms  which,  in  the  case  of  neuroses  of  the 
larynx,  represent,  almost  invariably  in  my  experience,  an  objec- 
tive condition.  The  so-called  parassthesia,  so  common  a  pre- 
monitor  of  incipient  phthisis,  represents  without  doubt  the  actual 
sensation  to  the  patient  of  tissue-changes  before  the  physician 
has  been  enabled  to  detect  them.  It  is  different  in  the  case  of  the 
sensation  which  a  patient  has  of  a  foreign  body  days  or  weeks 
after  a  particle  of  food  has  gone  the  wrong  way,  or  a  small  bone 
or  other  substance  has  worried  the  larynx.  This  is  a  true 
paraesthesia,  and  it  is  withal  a  condition  very  difficult  to  cure. 

Neuralgia  of  the  larynx  is  an  affection  which  has  received  but 
little  attention  from  laryngologists,  and,  in  the  true  sense  of  the 
term,  is  rare,  since,  although  patients  not  unfrequently  complain 
of  pain  in  the  larynx  as  their  only  symptom,  it  is  seldom  that 
objective  causes  cannot  be  found.    Of  these  the  most  frequent 


NEUROSES  OF  THE  LARYNX.  503 

are  general  anasmia,  and  especially  gouty  or  rheumatic  exacerba- 
tions ;  patients  who  suffer  from  laryngeal  neuralgia  being  almost 
always  subject  to  similar  affections  of  the  fifth  and  of  the  sciatic 
nerves. 

SyphiHs  plays  but  little  part  as  a  cause  of  the  affection  in  this 
region.  I  have  seen  not  a  few  cases,  thought  to  be  true  neuralgia 
in  people  of  advanced  age,  further  investigation  of  which  proved 
that  the  pain  was  due  to  commencing  chondrial  or  perichondria! 
changes. 

Careful  external,  in  addition  to  laryngoscopic,  examination  of: 
the  larynx  should  therefore  always  be  made  in  those  cases  in  which 
pain  is  a  prominent  manifestation.  The  noteworthy  symptoms 
in  laryngeal  neuralgic  affections  are  that  the  pain  is  often  uni- 
lateral, and  that  a  sensation  of  numbness  and  cold  along  the 
whole  of  the  affected  side  is  experienced,  in  addition  to  deep- 
seated  pain  more  or  less  distinctly  localized  in  one  spot.  Is  it  not 
possible  that  the  connection  of  the  facial  and  the  glosso-pharyn- 
geal  with  the  pneumogastric  at  its  origin,  and  of  the  sympathetic, 
has  more  to  do  with  the  occurrence  of  laryngeal  neuralgia  than 
any  affection  of  the  superior  laryngeal  nerve  itself? 

Treatment.—  Unfortunately,  this  disease  is  as  troublesome 
and  as  intractable  to  all  treatments  in  the  larynx  as  in  other  parts 
of  the  body.  Naturally  the  great  indication  is  to  discover,  and 
if  possible  remove,  the  cause.  Locally,  applications  of  chloral 
and  camphor,  aconite,  etc.,  and  hypodermic  injections,  give  relief, 
and  in  some  instances  the  inhalation  of  anodyne  vapours  is  effi- 
cacious (Form.  41  and  23).  General  treatment  need  not  here  be 
enlarged  upon,  except  to  say  that  in  my  practice  exhibition  of 
monobromide  of  camphor  has  been  attended  with  good  results 
(Form.  73).  In  one  case  a  course  at  Aix-les-Bains  was  recom- 
mended and  pursued  with  great  benefit.  A  relapse  occurred,  but 
a  second  course  at  the  same  spa  v/as  enjoined,  and  a  complete 
cure  resulted. 

NEUROSES  OF  MOTION  (Plate  X.). 

Paralysis  of  motion  may  be  partial  or  complete,  and  may  repre- 
sent either  defective  muscular  action  (paresis),  or  complete  abey- 
ance of  the  same  (paralysis). 

Partial  or  complete  loss  of  muscular  power  of  individual  laryn- 
geal muscles,  or  groups  of  muscles,  depends  on  such  varied 
causes,  and  is  capable  of  such  extended  analyses,  as  to  be  worthy 
not  only  of  much  more  attention  than  I  am  able,  either  by  space 


504 


DISEASES  OF  THE  THROAT  AND  NOSE. 


or  ability,  to  afford,  but — much  as  has  already  been  written — of 
even  something  much  more  complete  than  has  yet  appeared. 

The  division  of  these  affections  by  Von  Ziemssen  into  paralysis 
of  motion  in  the  domain  of  the  superior  laryngeal  nerve,  and  of 
those  in  the  domain  of  the  inferior  or  recurrent  laryngeal  nerve,  has 
been  generally  well  received.  It  was  the  arrangement  I  made  in 
my  former  edition,  and  I  see  no  reason  to  alter  it,  as  it  is  a  plan 
which  possesses  the  great  advantage  of  clinical  simplicity.  In 
recent  times  more  complete — albeit  more  complex — classifications 
have  been  suggested  and  adopted. 

^Gottstein  adopts  a  purely  clinical  division  of  '  laryngeal 
paralyses  according  to  the  functional  disturbance  produced  in 
each  variety:' 

1.  Paralysis  of  the  tensors  of  the  vocal  cords  ; 

2.  Paralysis  of  the  muscles  which  close  the  glottis  ; 

3.  Paralysis  of  the  muscles  which  open  the  glottis  or  abductors  j 

4.  Paralysis  of  all  the  muscles  supplied  by  the  recurrent. 

This  plan,  though  very  practical,  is  not  quite  so  scientific  as 
that  of  either  Lefferts  or  Mackenzie. 

*Lefferts,  at  the  International  Congress  in  1881,  proposed  the 
division  of  all  motor  neuroses  into  five  great  classes,  as  follows : 

1.  Motor  paralyses  of  the  larynx,  the  result  of  complete,  usually  acute,  morbid  implica- 
tion of  the  nerve-centres,  or  of  the  main  nerve-centres,  or  of  the  main  nerve-trunks,  the 
lesion  being  unilateral  or  bilateral ;  and  the  vocal  cord  or  cords  assuming  the  *  cadaveric ' 
position. 

2.  Motor  paralyses  of  the  larynx,  the  result  of  incomplete,  usually  slowly  progressive, 
lesion  of  either  the  nerve-centres,  or  more  commonly,  of  the  nerve-trunks  in  their  course  ; 
certain  nuclei  of  the  former,  or  certain  fibrils  of  the  latter,  alone  being  implicated,  certain 
muscles  alone  are  paralyzed  ;  the  abductor  muscles  of  the  glottis  being  practically  the 
only  ones  thus  affected. 

3.  Motor  paralyses  of  individual  muscles  of  the  larynx,  the  result  of  implication  of  cer- 
tain peripheral  nerve-twigs,  by  local  or  intra-laryngeal  lesion. 

4.  Motor  paralyses  of  single  or  groups  of  laryngeal  muscles,  the  result  of  simple  myo- 
patJiic  changes  in  the  said  muscles  of  a  degenerative  character. 

5.  Motor  paralyses,  functional  in  their  nature,  the  adductor  muscles  being  the  ones 
commonly  affected,  the  abductors  very  rarely. 

The  details  of  this  classification  were  explained  with  all  the 
accustomed  lucidity  of  its  author,  and  its  adoption  urged  with 
equally  characteristic  enthusiasm,  and,  indeed,  there  is  much  to 
be  said  in  its  favour.  But  ^  Morell-Mackenzie,  who  speaks  with 
high  authority  on  this  subject,  has  entirely  changed  his  original 
classification,  and  has  proposed  quite  a  new  one  which  may  be 
called  pathological,  in  contradistinction  to  that  of  Lefferts  which 
is  more  essentially  clinical.  Dividing  neuroses  of  motion  into  the 
two  natural  classes,  viz.,  (i)  loss  of  power,  or  paralysis,  and  (2) 
perverted  power,  or  spasm,  under  the  former  Mackenzie  gives  : 


NEUROSES  OF  THE  LARYNX. 


505 


1.  Paralysis  fron-.  disease  or  injury  of  that  portion  of  the  inediiU.a  cblougata  which  con- 
stitutes the  floor  of  the  fourth  ventricle  ; 

2.  Paralysis  from  disease  or  injury  of  the  spinal  accessory  nerve  ; 

3.  Paralysis  from  disease  or  injury  of  the  p)mimogastric  nerve  ; 

4.  Paralysis  from  disease  or  injury  of  the  superior  or  laryngeal  nerve  ; 

•  5.  Paralysis  from  disease  or  injury  of  the  recurrent  laryngeal  nerve  ;  and 

6.  Paralysis  of  individual  muscles  or  sets  of  muscles — a  class  of  affections  which, 
though  generally  of  myopathic  nature,  can  be  most  conveniently  considered  in  this 
subdivision. 

The  clinical  usefulness  of  this  undoubtedly  scientific  classifica- 
tion is  not  so  great  as  would  at  first  sight  appear.  For  instance, 
injury  of  the  medulla  (i)  *  involves  paralysis  of  almost  any  laryngeal 
muscles  or  groups  of  muscles  '  without  distinction  ;  while  paralysis 
from  a  lesion  of  the  spinal  accessory  (2)  is  unpractical,  since,  to 
quote  the  author  under  notice,  '  the  S3/mptoms  of  uncomplicated 
disease  of  the  accessory  nerve  are  not  at  present  known.'  Lastly, 
this  classification  necessitates  the  treatment  of  some  paralyses 
under  three  or  four  separate  headings. 

Solis  Cohen  adheres  to  the  original  and  simpler  plan  of 
Mackenzie  and  of  Von  Ziemssen,  of  considering  paralyses  of 
each  individual  muscle  and  group  of  muscles  separately. 

I  have  enumerated  these  different  classifications,  because  they 
indicate  pretty  plainly  the  various  aspects  from  which  this  vast 
subject  may  be  viewed ;  but  I  must  refer  the  reader  to  the  works 
of  the  original  authors  for  the  justification  and  elaboration  of 
their  separate  systems.  Whichever  be  adopted,  the  chnical  facts 
remain  the  same. 

PARALYSIS  IN  THE  DOMAIN  OF  THE  SUPERIOR  LARYNGEAL 

NERVE. 

This  principally  occurs  in  connection  with  paralysis  of  sensa- 
tion, and  impHes  loss  of  povv^er  in  the  crico-thyroid,  thyro- 
epiglottic, and  ary-epiglottic  muscles.  It  is  important  to  diag- 
nosticate it  in  all  those  cases  in  which  the  muscles  supplied  by 
the  recurrent  are  also  attacked,  as  in  such  a  case  there  will  be 
disease  or  pressure  on  the  main  nerve-trunk.  In  other  cases  it 
may  be  peripheral,  and  is  then  generally  a  sequel  of  diphtheria. 

The  SYMPTOMS  are  mainly  those  of  anaesthesia,  inaction  of 
the  epiglottis,  allowing  the  passage  of  food  into  the  larynx  when 
the  muscles  connected  with  the  epiglottis  are  attacked  ;  there 
is  also  a  hoarse  tone  of  voice  and  inability  to  produce  high 
notes,  with  a  sense  of  fatigue  after  exercise  of  function  ;  these 
symptoms  are  due  to  impairment  of  tension  (an  act  performed  by 
the  crico-thyroid  muscle).    Frequently  associated  with  this  form 


5o6  DISEASES  OF  THE  THROAT  AND  NOSE. 

of  paraWsis  is  a  want  of  co-ordinative  power,  a  condition  not, 
however,  peculiar  to  neuroses  of  this  region  only.  The  general 
nervous  lesion,  when  exhibited  in  a  mild  degree,  is  often  the 
over-use  of  the  voice,  especially  during  catarrh,  impairment  of 
tension  being,  in  point  of  fact,  commonly  found  in  chronic 
lar3mgitis.  One  of  many  such  cases  came  under  my  notice  in 
1878  : 

If-  was  that  of  a  young  lady,  sent  by  Dr.  Gowers,  vvho,  after  some  months  of  choir- 
teaching  and  leading,  found  her  singing-voice  greatly  deteriorated,  especially  in  the  pro- 
duction of  the  higher  notes,  and  in  the  power  of  singing  for  even  a  few  minutes.  There 
was  a  clear  history  of  forcing  of  the  voice,  and  continuance  of  its  use  during  a  catarrhal 
attack.  The  larynx  was,  however,  perfectly  healthy  (and  it  may  here  be  stated  that  I 
have  never  noticed  the  wavy  line  in  the  glottic  space  depicted  by  Mackenzie)  ;  but  there 
was  congestion  of  the  veins  in  the  posterior  wall  of  the  pharynx,  and  slight  granulation. 
An  opinion  was  given  that  the  condition  was  due  to  irritation  of  the  superior  laryngeal 
nerve,  from  its  connection  with  the  pharyngeal  plexus,  thus  inducing  paresis  of  the  crico- 
thyroid ;  and  such,  it  is  believed,  is  the  cause  in  all  cases  of  paralysis  of  the  superior 
laryngeal,  in  which  there  is  not  corresponding  enervation  of  the  muscles  supplied  by  the 
inferior. 

Such  cases  might  be  multiplied  almost  ad  infinitum.  They  are 
of  daily  occurrence.  I  am  aware  that  paralysis  of  the  crico-thyroid 
alone  is  of  extreme  rarity,  and  likewise  that  this  muscle  probably 
receives  nervous  supply  from  the  inferior,  as  well  as  the  superior 
laryngeal  nerve  ;  but  I  have  no  doubt  that  the  crico-thyroid  is  the 
main,  if  not  the  only  tensor,  of  the  vocal  cords  ;  and  the  associa- 
tion of  want  of  tension,  evidenced  by  inability  to  take  high  notes, 
and  of  chronic  pharyngitis  is  of  too  frequent  occurrence  to  allow 
the  opinion  that  it  is  accidental. 

Treatment. — This  should  be  carried  out  on  the  Hnes  laid 
down  in  the  remarks  pertaining  to  diphtheritic  paralysis  (p.  350)- 
and  to  chronic  pharyngitis  (p.  191).  When  occurring  in  connec- 
tion with  the  latter  disease,  faradization  is  of  little  service,  unless 
the  pharyngeal  inflammation  has  been  first  subdued.  To  render 
any  cure  permanent,  careful  examination  should  be  made  for  the 
particular  vocal  defect  which  originated  the  attack,  and  a  course 
of  teaching  enjoined  which  should  lead  to  its  correction. 

PARALYSIS  IN  THE  DOMAIN  OF  THE  INFERIOR  OR  RECUR- 
RENT LARYNGEAL  NERVE. 

Under  this  head  will  be  considered  impairment  of  motion  of 
all  the  muscles  supplied  by  this  nerve  ;  in  other  words,  of  all  the 
intrinsic  muscles  of  the  larynx.  The  special  forms  are  paralysis 
of  adductors,  bilateral  or  unilateral;  paralysis  of  abductors,  bi- 
lateral or  unilateral;  and  paralysis  of  the  sphincters,  otherwise 
called  the  laxors,  and  by  some  the  tensors,  of  the  vocal  cords. 


NEUROSES  OF  THE  LARYNX. 


Muscular  palsies  due  to  implication  of  this  nerve  are  much 
more  varied,  more  frequent,  and  more  serious  than  those  of  the 
superior  laryngeal,  since  the  number  of  muscles  supplied  by  it 
w^ith  motor  power  is  so  much  greater.  The  causes  w^hich  may 
give  rise  to  them  may  be  central  (cases  of  which  are  rare)  ;  or 
there  may  be  disease  of  the  parent  trunk  at  its  point  of  origin 
(also  rare),  or  in  its  course  ;  or  of  the  recurrent,  either  in  its 
course  (the  most  common  cause)  or  at  its  peripheral  extremities. 

Paralyses  of  laryngeal  muscles  of  central  origin  are  usually 
dependent  on  disease  of  some  portion  of  the  medulla  oblongata, 
and  are  always  associated  with  a  like  palsy  of  other  muscles  of  the 
palate,  tongue,  head,  face,  or  extremities. 

Krause's  experiments  have  satisfactorily  demonstrated  that  the 
motor  cortical  centre  of  the  muscles  of  the  pharynx  and  larynx 
is  situated  in  the  gyrus  prcefrontalis.  Its  position  is  almost — if 
not  quite — identical  with  that  of  the  speech  centre  ;  but  whereas 
the  latter  is  unilateral,  that  of  the  former  is  distinctly  bilateral. 
Hence,  although  in  a  cortical  lesion  of  the  left  side  only  there  is 
aphasia,  the  movements  of  the  larynx  are  not  appreciably  affected, 
on  account  of  the  bilateral  associations  of  the  two  centres. 

Cases  of  traumatic  injury  of  the  trunk  from  gun  or  sabre 
wounds  have  been  reported,  as  also  of  injury  from  pressure  by 
various  tumours.  These  latter  causes  will  exert  an  injurious 
influence  on  the  recurrent  in  its  course,  while  catarrh,  rheumatism, 
excessive  laryngeal  exertion,  perichondrial  and  chondrial  changes, 
ulcerations  and  new  formations  in  the  larynx,  may  induce  peri- 
pheral enervation. 

It  is  comparatively  seldom  that  one  muscle  or  one  set  of 
muscles  only  is  affected,  and  the  division  into  paralysis  of  the 
muscles  affecting  the  function  of  voice,  and  of  those  affecting  that 
of  respiration,  although  now  fallen  into  disuse,  was  not  without 
practical  value. 

As  we  have  seen,  paralysis  of  the  crico-thyroid,  supplied  by  the 
superior  laryngeal  nerve,  almiost  always  involves  the  muscles 
acting  on  the  epiglottis,  and  it  is  not  unfrequently  attended  with 
some  loss  of  power  of  the  other  muscles  which  assist  in  tension 
of  the  vocal  cords  ;  viz.,  the  internal  thyro-arytenoids  and  the 
posterior  crico-arytenoids.  In  paralysis  of  the  adductors,  impair- 
ment of  the  action  of  the  lateral  crico-arytenoids  is  coupled  with 
that  of  the  arytenoideus  ;  and  this  last-named  muscle  is,  on  post- 
mortem examination,  generally  found  to  be  diseased  in  those 
cases  in  which  death  has  been  caused  by  paralysis  of  the  posterior 
crico-arytenoids.    Unilateral  paralysis  of  the  adductors  is  also 


5o8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


seldom  of  a  pure  character,  there  being  generally  some  impair- 
ment of  abduction  and  of  tension.  In  this  class  of  diseases  the 
impairment  of  the  to-and-fro  motion  of  the  cords  varies  the  shape 
of  the  glottic  orifice.  In  some  cases  one  or  both  cords  rest  mid- 
way between  full  adduction  and  complete  abduction,  and  the 
position  then  taken  is  that  which  may  be  observed  in  the  normal 
larynx  after  death.  Von  Ziemssen  has  appropriately  called  this 
the  '  cadaveric  position,'  and  this  term  will  be  here  adopted, 
since  it  tersely  expresses  a  standard  of  comparison  (Fig.  92, 
Plate  X.). 

The  diagnosis  of  the  various  palsies  by  the  aid  of  the  laryngo- 
scope is  thus  easily  mastered,  though  the  causes  can  only  be 
accurately  inferred  after  careful  examination  with  stethoscope, 
ophthalmoscope,  sphygmograph,  and  other  instruments  of  pre- 
cision. 

The  prognosis  is  in  a  large  number  of  cases  favourable,  but 
should  always  be  cautious,  as  the  detailed  account  of  the  principal 
varieties  will  indicate.  In  very  many  cases,  treatment,  especially 
of  an  electrical  character,  is  strikingly  and  permanently  beneficial. 

BILATERAL  PARALYSIS  OF  ADDUCTORS— CRICO-ARYTENOIDEI 
LATERALES  AND  ARYTENOIDEUS  (Fig.  93,  Plate  X.). 

This  condition  is  generally  due  to  functional  causes,  the  prin- 
cipal of  which  is  general  anaemia.  Complete  loss  of  voice  is 
occasionally  experienced  after  recovery  from  certain  diseases 
which  impoverish  the  blood.  The  history  of  many  other  cases  is 
that  of  enfeeblement  from  long  nursing  of  a  sick  relative,  and 
similar  causes,  tending  to  produce  at  the  same  time  bodily  weak- 
ness and  mental  prostration.  I  cannot  agree  with  Mackenzie, 
that  '  it  far  less  commonly  occurs  in  connection  with  amenorrhcea 
than  might  be  supposed  from  the  writings  of  some  authors,'  for, 
according  to  my  experience,  amenorrhcea  or  dysmenorrhoea  is  the 
more  frequently  coexistent  uterine  condition ;  and  the  most 
favourable  periods  of  life  for  its  occurrence  in  females  are  at  the 
commencement  and  on  cessation  of  menstruation.  Allusion  has 
been  made  in  the  chapter  on  laryngeal  phthisis  to  the  frequent 
recurrence  of  functional  aphonia  as  a  premonitor  of  that  disease : 
in  such  a  case  it  is  a  question  whether  enfeeblement  of  motor 
power  in  the  lungs  or  local  anaemia  is  the  principal  tactor.  It  is 
certainly  the  former  in  the  later  stages  of  laryngeal  tuberculosis, 
to  which  is  added  the  separation  of  the  arytenoid  cartilages  by 
tumefaction.  Functional  aphonia  is  much  less  frequently  purely 
hysterical  than  is  generally  considered,  and  the  term  *  hysterical 


NEUROSES  OF  THE  LARYNX. 


509 


loss  of  voice '  but  too  frequently  represents  a  want  of  inclination 
or  ability  to  find  out  the  true  cause.  It  not  uncommonly  occurs 
on  the  subsidence  of  a  laryngeal  catarrh,  and  it  is  occasionally 
produced  by  sudden  fright. 

•5  Whitfield  Ward,  in  a  very  suggestive  though  brief  paper,  has 
usefully  drawn  attention  to  the  circumstance  that  '  paralysis  of 
adduction  may  be  subdivided  into  three  forms,  namely,  a  paresis 
of  the  arytenoideus,  a  paresis  of  the  crico-arytenoidei  laterales, 
and  lastly,  a  paresis  of  the  arytenoideus  and  crico-arytenoidei 
laterales  combined.'  I  do  not  quite  follow  this  author  when  he 
says  that  '  the  arytenoideus  muscle  is  the  principal  agent  in  the 
production  of  the  affection  styled  paralysis  of  adduction for  it 
must  be  remembered  that  the  arytenoideus,  when  acting  inde- 
pendently of  the  crico-arytenoidei  laterales,  exerts  but  a  partial 
influence  on  adduction;  on  the  other  hand,  when  acting  in  concert 
with  the  crico-arytenoidei  postici,  its  movement  is  distinctly  that 
of  abduction. 

Symptoms. — The  voice  is  simply  lost,  or  absent,  but  involuntary 
acts,  such  as  coughing  and  laughing,  are  phonetic;  when  the 
aphonia  is  the  result  of  catarrhal  conditions,  however,  these 
sounds  are  more  or  less  hoarse.  In  purely  hysterical  cases  there 
is  frequently  corresponding  functional  paralysis  of  the  lips  and 
muscles  of  speech,  constituting  functional  loss  of  speech  as  well 
as  of  voice.  The  respiration  is  often  somewhat  hurried,  and  if 
the  affection  be  allowed  to  remain  long  untreated,  the  lungs  are 
liable  to  suffer.  Other  functional  acts  are  unimpeded,  and  there 
is  an  entire  absence  of  pain. 

Laryngoscopic  examination  shows  that  on  attempted  phona- 
tion  the  vocal  cords  do  not  approach  the  median  line.  There  is 
also  generally  witnessed  some  diminution  in  the  power  of  separa- 
tion when  the  patient  attempts  to  take  a  deep  breath.  Absence 
of  any  new  formation,  or  other  mechanical  impediment  to  approxi- 
mation of  the  cords,  will  complete  the  diagnosis.  The  mucous 
membrane  is  generally  pale  in  colour,  though  in  catarrhal  cases 
its  hue  may  be  deepened. 

Prognosis. — Recovery  from  this  condition,  under  suitable 
treatment,  is  for  the  most  part  speedy,  though  every  now  and 
again  one  meets  with  an  instance  obstinate  to  all  efforts :  in 
relation  to  life,  the  most  favourable  opinion  may  be  given,  though 
the  possibility  of  a  tubercular  tendency  must  not  be  lost  sight  of. 

Treatment. — If  stimulating  inhalations,  general  tonics,  and 
change  of  air  fail,  faradization  should  be  employed.  In  many 
cases,  if  the  current  of  one  pole  be  applied  to  the  back  of  the 


5IO  DISEASES  OF  THE  THROAT  AND  NOSE. 


Longue,  and  the  other  over  the  thyroid  region,  the  voice  will  be 
restored ;  but  when  this  does  not  avail,  there  should  be  no  hesi- 
tation in  introducing  the  electrode  within  the  larynx.  These 
applications  should  be  continued  daily  till  the  voice  is  permanently 
restored. 

Those  hysterical  cases  are  without  doubt  the  more  intractable  in 
which  a  lengthened  course  of  toying  with  this  valuable  therapeutic 
agent  has  been  indulged  in ;  for  no  better  word  can  be  employed 
to  designate  the  long-continued  use  of  external  galvanism  applied 
by  the  patient  or  by  friends.  Allusion  has  been  made  to  the 
diminished  sensibility  of  the  larynx  in  purely  hysterical  cases ; 
but  care  must  be  taken,  in  applying  the  current  for  the  first  time, 
that  the  power  be  not  too  strong,  lest  the  fright  thereby  induced 
serve  only  to  increase  the  malady  intended  to  be  relieved.  Of 
this  I  have  seen  several  examples. 

In  many  cases  strong  moral  influence  is  necessary  to  prevent 
the  voice,  once  restored,  from  lapsing  back  to  the  whisper,  an 
event  which  may  be  considered  as  the  result  of  habit  of  the 
larynx.  In  some  instances  in  which  aphonia  occurs  at  the  meno- 
pause there  is  occasionally  some  functional  dysphagia,  associated 
also  with  neuralgia;  in  these  cases  the  electric  bath  and  the 
constant  current  may  be  employed  in  addition  to  topical  remedies. 

UNILATERAL  PARALYSIS  OF  ADDUCTORS  (Fig.  94,  Plate  X.). 

*This  rare  condition  may  be  due  to  chronic  toxcemia,  lead, 
arsenic,  diphtheria,  etc. ;  may  result  from  cerebral  disease,  or 
may  be  caused  by  cold  or  muscular  strain ;  and  is  met  with  after 
small-pox,  in  constitutional  syphilis,  and  in  phthisis'  (Mackenzie). 

Symptoms. — Unless  the  brain  be  affected,  loss  of  voice  or 
hoarseness  is  the  chief  functional  sign  ;  but  the  acts  of  coughing, 
sneezing,  and  laughing  are  also  aphonic  or  of  diminished  phonetic 
power.    Difficulty  of  swallowing  is  sometimes  experienced. 

With  the  laryngoscope,  the  affected  cord  is  seen,  on  attempted 
phonation,  to  be  immobile,  and  to  remain  in  the  cadaveric 
position  while  the  healthy  cord  acts  freely.  There  is  the  same 
diminished  pov;er  of  abduction  as  in  the  bilateral  paralysis.  The 
only  point  of  value  in  diagnosis  is  the  possibility  that  the  inaction 
may  be  due  to  perichondrial  inflammation,  the  swelling  in  this 
condition  being  often  beneath  the  vocal  cords,  and  hable,  there- 
fore, to  pass  unnoticed. 

Prognosis  is  favourable  when  the  cause  is  local. 

Treatment. — Faradization  is  of  great  value  in  toxaemic  cases, 
and  should  be  accompanied  by  stimulant  inhalations  and  tonics. 


NEUROSES  OF  THE  LARYNX, 


BILATERAL  PARALYSIS  OF  ABDUCTORS-CRICO-ARYT^- 
NOIDEI  POSTICI  (Fig.  95,  Plate  X.). 

This  rare  condition  is  the  most  serious  of  the  individual 
paralyses  of  the  larynx,  since  it  implies  almost  complete  closure 
of  the  portal  of  '  the  breath  of  life,'  and  gives  rise  to  stridor, 
dyspnoea,  and  even  asphyxia. 

Etiology. — Mackenzie  considers  the  causes  of  the  condition  to 
be  generally  cerebral ;  but  an  analysis  of  nine  reported  cases  col- 
lected by  Von  Ziemssen,  of  which  three  were  fatal,  shows  that 
in  one  of  these  there  was  compression  of  both  recurrent  trunks ; 
in  the  second  there  was  no  evidence  of  even  microscopic  altera- 
tion of  either  recurrent  or  pneumogastric,  and  only  in  the  third 
was  there  disease  of  the  root  of  the  pneumogastric  and  spinal 
accessory.  Of  the  six  cases  in  which  death  was  not  reported,  one 
occurred  after  typhoid  fever,  another  after  pneumonia  following 
erysipelas  ;  and  in  the  four  other  cases  the  origin,  though  doubtful, 
was  as  likely  as  not  dependent  on  catarrhal  influences.  Analysis 
of  the  increased  number  of  cases  reported  since  publication  of  the 
foregoing  do  not  alter  these  facts. 

Any  new  growth,  whether  it  be  simple,  glandular,  hypertrophic, 
or  of  an  aneurismal  or  malignant  nature,  if  it  press  upon  both 
recurrents,  may,  of  course,  produce  bilateral  paralysis.  '^Baumler 
has  narrated  one  interesting  case  of  bilateral  palsy  from  pericardial 
exudation. 

Symptoms  :  A.  Functional  or  Subjective. — Voice  may  be 
but  little  affected,  at  least  in  the  moderate  functional  use  neces- 
sary for  quiet  conversation,  but  may  be  slightly  hoarse  if  com- 
plicated by  even  slight  catarrh.  No  observations  have,  so  far  as 
I  am  aware,  been  made  with  regard  to  the  singing  voice,  but  one 
would  naturally  expect  that  both  tensor  power  and  sustaining 
quality  would  be  enfeebled. 

Respiration. — This  is  the  function  which  is  most  seriously 
impeded  ;  the  impairment  consisting  in  extreme  inspiratory  stridor, 
ex-spiration  being  normal.  This  condition  is  first  evidenced  on 
exertion,  as  in  going  upstairs,  but  is  later  manifested  in  an  extreme 
degree  during  sleep ;  so  much  is  this  the  case,  that  one  instance 
has  been  reported  in  which  it  became  necessary  to  remove  a 
patient  to  a  room  in  the  garden  of  a  hospital,  as  the  whole  wards 
were  disturbed  by  his  unconscious  *  howls.'  Naturally  the  repeated 
suction  of  blood  into  the  pulmonary  vessels,  by  chest  expansion 
during  closure  of  the  glottis,  leads  to  severe  congestion  of  the 
lungs;  this,  if  not  relieved,  eventuates  in  carbonic  acid  poi^^ouing. 


512 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Cough  is  not  necessarily  a  prominent  symptom ;  when  present,  it 
may  be  wanting  in  tone,  or  when  the  paralysis  is  incomplete,  it  is 
loud  and  howling. 

B.  Physical  or  Objective. — There  need  be  but  Httle  altera- 
tion in  the  colour  or  surface-texture  of  the  larynx,  but  the  laryn- 
geal mirror  at  once  reveals  the  condition  by  the  fact  that  the 
glottic  space  is  seen  to  be  reduced  to  a  mere  slit  (not  an  ellipse, 
as  in  paralysis  of  the  thyro-arytenoids) ;  and  as  a  further  charac- 
teristic, it  is  seen  that  this  narrowed  opening  is  smaller  during  the 
inspiratory  than  during  the  ex-spiratory  act.  This  phenomenon 
is  explained  by  *  excess  of  external  atmospheric  pressure  over  that 
of  the  rarefied  air  within  the  trachea,  while  in  ex-spiration  the 
glottis  returns  to  its  original  size.  On  phonation  the  linear  slit  is 
narrowed  in  a  normal  manner,  and  the  vibrations  of  the  vocal 
cords  show  nothing  abnormal.' 

C.  Miscellaneous. — Externally  there  may  be  evidence  of 
glandular  or  other  enlargements,  and  on  auscultation  there  may 
be  found  the  signs  of  an  aneurismal  or  glandular  growth  in  the 
mediastinum,  though  the  loudness  of  the  inspiration  is  frequently 
a  great  hindrance  to  accurate  stethoscopic  diagnosis.  There  is 
naturally  much  constitutional  derangement  and  wasting. 

Differential  Diagnosis. — The  only  disease  which  could  be 
mistaken  for  this  condition  is  one  equally  serious  and  still  more 
rare,  viz.,  cicatricial  fixation  and  adhesion  of  the  arytenoid  carti- 
lages from  syphilitic  ulceration,  of  which  one  case  has  been 
reported.  In  spasm  of  the  glottis,  the  variation  in  the  appear- 
ance at  different  periods  wi41  at  once  clear  up  the  diagnosis. 

Prognosis,  Course,  and  Termination. — This  affection  is,  of 
course,  most  serious,  but  it  is  by  no  means  hopeless,  provided  it 
be  not  due  to  central  lesion  or  destructive  tumours.  Of  the  nine 
cases  previously  referred  to,  three  were  reported  as  living  long 
after  the  introduction  of  a  canula ;  two  either  improved  or  re- 
mained stationary,  without  the  necessity  for  operative  interference; 
and  one  received  distinct  benefit  from  electrical  treatment.  In 
those  cases  in  which  death  occurs,  there  is  always  found  atrophy 
and  fatty  degeneration  of  the  posterior  crico-arytenoid  muscles. 

Treatment. — Even  if  the  origin  be  central,  life  may  be  pro- 
longed and  the  distress  of  the  patient  greatly  relieved  by  the 
performance  of  tracheotomy.  Mackenzie  considers  electrical 
treatment '  scarcely  a  safe  procedure,'  but  in  the  only  recorded  case 
in  which  decided  improvement  took  place — that  of  Von  Ziemssen 
— the  benefit  was  entirely  due  to  the  alternate  application  of  the 
induced  and  the  constant  currents. 


NEUROSES  OF  THE  LARYNX. 


513 


In  the  cases  of  ^Gerhardt  and  ^Nicoks  Duranty,  the  same  treat- 
ment, although  followed  by  no  benefit,  was  equally  unattended  by 
any  injurious  result. 

Since  the  foregoing  was  written  in  1878,  I  have  had  two  hospital 
cases  which  benefited  greatly — one  to  the  extent  of  a  cure — by  the 
long-continued  hypodermic  injection  of  strychnia.  The  treatment 
was  pursued  in  conjunction  with  my  colleague  Dundas  Grant. 

UNILATERAL    PARALYSIS   OF  AN  ABDUCTOR   (Figs.  96  and  97, 

Plate  X.). 

This  disease  is  by  no  means  so  rare  as  the  preceding.  It 
implies  pressure  on  the  recurrent  nerve  supplying  the  affected 
muscle ;  and  from  the  anatomical  situation  of  the  nerve,  the  left 
side  is  much  more  frequently  affected  than  the  right. 

Etiology. — The  sources  of  origin  of  unilateral  abductor  par- 
alysis are  much  the  same  as  those  of  the  bilateral  form.  Most 
frequently  there  is  pressure  or  stretching  of  the  recurrent  itself, 
but  the  cause  may  primarily  be  located  in  the  trunk  of  the 
pneumogastric.  Aneurism  of  the  arch  of  the  aorta,  enlargement 
of  the  bronchial  glands  around  the  root  of  the  lung  or  in  the 
course  of  the  nerve,  hypertrophy,  whether  simple  or  malignant, 
of  the  thyroid  gland,  carcinoma  of  the  anterior  wall  of  the 
oesophagus  with  infiltration  in  the  vicinity  of  the  disease,  or 
syphilitic  cicatricial  narrowing — may  all  involve  the  left  recurrent. 
Similar  causes  may  produce  enervation  on  the  right  side,  except 
that  aneurism  will  be  of  the  innominate  or  subclavian  instead  of 
the  aorta ;  and  peculiar  to  this  side  is  induration  of  the  apex  of 
the  lung  (p.  385). 

A  subject  that  has  received  much  attention  of  late  years  is, 
whether  there  is  or  is  not  a  distinct  '  proclivity  of  the  abductor 
fibres  of  the  recurrent  laryngeal  nerve  to  become  affected  sooner 
than  the  adductor  fibres,  or  even  exclusively,  in  cases  of  un- 
doubted central  or  peripheral  injury  or  diseases  of  the  roots  or 
trunks  of  the  pneumogastric,  spinal  accessory,  or  recurrent  nerves.' 
This  view  has  been  advanced  with  great  enthusiasm  and  reitera- 
tion by  ^°Semon,  and  several  experiments,  with  a  view  of  con- 
firmation, have  been  conducted  by  him  in  conjunction  with 
^^Horsley.  Into  the  merits  of  the  discussion  I  do  not  intend  to 
enter  at  any  great  length  critically,  more  especially  since  I  am 
inclined  to  the  belief  that  the  clinical  importance  of  the  fact,  if 
fact  it  be,  is  not  so  great  as  is  often  advanced.  But  it  is  only  right 
to  say,  in  the  first  place,  that  the  view  originated  with  ^^Qttomar 
Rosenbach,  of  Breslau,  and  that  the  same  idea  had  in  a  measure 

33 


514 


DISEASES  OF  THE  THROAT  AND  NOSE. 


been  foreshadowed  long  previously  by  Gerhardt,  Mackenzie,  and 
others.  Observation  with  the  laryngoscope  decidedly  leads  one 
to  the  conclusion  that  in  all  cases  of  interference  with  the  recur- 
rent, there  is,  apparently  at  least,  an  earlier  evidence  of  paralysis  ol 
abduction  than  of  adduction  ;  and  it  is  this  circumstance  that 
has  probably  led  Lefferts,  Gottstein,  McBride,  and  others  to 
accept  Semon's  conclusions  on,  so  far  as  can  be  gathered,  no 
other  than  clinical  corroboration.  But,  on  the  other  hand, 
they  have  been  contradicted  with  great  vigour  by  Hooper  and 
Frank  Donaldson,  jun.,  both  of  whom  have  made  numerous 
and  most  careful  experiments  in  support  of  their  opinions.  The 
investigations  of  Hooper  were  conducted  in  the  Physiological 
Laboratory  of  Harvard  University  ;  those  of  Donaldson  in  the 
Biological  Laboratory  of  the  Johns  Hopkins  University,  and  were 
made  under  the  supervision  of,  or  in  co-operation  with,  eminent 
physiologists  connected  with  these  important  institutions.  More- 
over, the  dictum  was  received  with  by  no  means  universal  assent 
at  a  recent  meeting  in  Berlin,  ^'^Krause  being  especially  opposed 
to  it.  Cohen  also  distinctly  dissents  from  Semon's  '  sweeping 
conclusion,  and  confesses  an  inability  to  discriminate  between  the 
position  of  the  vocal  bands  in  extreme  abduction — their  position 
during  forced  inspiration,  and  their  position  in  relaxation  (cadaveric 
position).'  This  is  generally  the  view  I  had  myself  taken  in  dis- 
cussion of  the  subject  from  time  to  time  with  my  colleagues, 
especially  with  Dundas  Grant,  before  these  words  of  Cohen  were 
written.  We  had  also  remarked,  as  we  find  Cohen  has  done, 
that  no  notice  is  taken  in  this  connection  of  the  part  the  superior 
laryngeal  nerve  may  play  in  the  transaction.  It  is  quite  certain 
that  the  sphinctor  and  tensor  action  of  all  the  muscles  so  supplied 
is  in  a  large  sense  adductive,  and  this  circumstance  may  account 
for  the  appearance  of  greater  loss  of  the  abductive  power  of  the 
cords  in  cases  of  pressure  on  the  recurrent  nerve  over  that  of 
adduction,  quite  independently  of  any  actual  'proclivity  to  ab- 
ductor paralysis.'  As  Cohen  further  says :  'It  is  not  known 
whether  the  double  function  of  the  recurrent  nerve  is  due  to 
innervation  by  a  common  centre,  or  whether  distinct  centres 
preside  over  separate  sets  of  filaments ;  while  the  influence  which 
the  nucleus  of  the  pneumogastric  may  exercise  upon  abduction 
of  the  vocal  bands  as  an  organic  feature  of  the  respiratory  act, 
is  a  problem  yet  unsolved.'  Cohen's  suggestive  remarks  have 
received  confirmation  through  the  more  accurate  knowledge 
recently  afforded  on  the  subject  of  the  innervation  of  the  larynx. 
1' Mandlestamm  has  demonstrated  that  the  inter-arytenoid  and 


NEUROSES  OE  THE  LARYNX. 


the  internal  thyro-arytenoid  muscles  are  supplied  by  the  superior 
laryngeal  nerve.  The  inter-ar3'tenoid  is  also  innervated  by  both 
recurrents,  so  that  unilateral  injur}^  to  the  nerve  will  not  affect  its 
adductive  powder  of  that  side.  ^^Exner's  experiments  and  obser- 
vations are,  if  possible,  still  more  interesting.  The  principal 
facts  of  present  application  are  that  w^hile  the  external  thyro- 
arytenoid muscle  is  supplied  chiefly,  if  not  exclusively,  by  the 
inferior  or  recurrent  laryngeal  nerve,  the  internal  thyro-arytenoid 
derives  a  large  share  of  its  innervation  from  the  superior  laryngeal 
nerve.  Exner  has  also  demonstrated  the  existence  of  a  third  or 
median  laryngeal  nerve  in  the  rabbit  and  dog,  and  suggests  that 
in  the  human  subject  this  nerve  probably  lies  in  the  pharyngeal 
and  laryngeal  plexus  ;  but  it  is  difficult  to  trace  it  into  the  crico- 
thyroid muscle.  This  median  branch  is  believed  to  be  of  great 
motor  importance.  Both  Exner  and  Weinzv^^eig  have  demon- 
strated the  crossing  of  the  nerves  of  the  larynx,  especially  of  the 
superior  laryngeal,  from  one  side  to  the  other.  With  every  respect, 
therefore,  for  the  many  elaborate  and  ingenious  arguments  that 
have  been  advanced,  we  are  precluded,  in  the  light  afforded  by  all 
these  opposing  considerations,  from  giving  our  adhesion  to  the 
views  of  Rosenbach  and  Semon  on  this  question,  or  at  least  from 
acceptance  of  them  in  their  entirety. 

Symptoms:  A.  Functional  or  Objective. — Voice  is  always 
rough,  harsh,  impure,  and  unequal  in  tone,  or  distinctly  hoarse, 
but  is  seldom  or  never  aphonic. 

Respiration. — Inspiratory  stridor  is  characteristic  of  this  affec- 
tion, as  of  the  bilateral  form,  but  the  difficulty  of  breathing  is  by  no 
means  so  exaggerated,  and  may  be  even  unaffected.  The  slightest 
catarrhal  influences  may  produce  severe  exacerbations. 

B.  Physical  or  Objective. — There  is  usually  some  general 
congestion  of  the  mucous  membrane,  especially  of  the  affected 
vocal  cord,  which,  with  the  laryngoscope,  is  seen  not  to  depart 
from  the  middle  line  ;  or  often,  there  is  some  paralysis  of  adduc- 
tion also,  which  causes  it  to  assume  the  cadaveric  position.  This 
is  especially  observed  in  those  cases  due  to  glandular  enlargement 
and  to  syphilitic  deposit. 

C.  Miscellaneous. — Nothing  more  need  be  said  under  this 
head  than  was  stated  in  considering  the  preceding  affection. 
Pain  and  disorder  of  deglutition  will  be  observed,  should  the 
disease  be  malignant  and  the  oesophagus  be  thereby  involved. 

Prognosis,  Course,  and  Termination. — A  most  serious 
opinion  must  be  given  in  every  case  of  this  nature,  since  the 
disease  which  gives  rise  to  it  is  so  frequently  of  a  fatal  character. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


It  is  probable  that  formerly  the  prognosis  was  often  unnecessarily 
grave,  but  the  contrary  fault  seems  in  danger  of  being  now  com- 
mitted. Cases  do,  however,  every  now  and  then  come  under 
notice,  in  which  the  paralysis  assumes  a  chronic  and  remittent 
form. 

Such  a  one  occurred  in  my  practice  in  the  instance  of  a  lady,  aqjed  53,  first  seen  in 
August,  1873,  who  suffered  from  occasional  severe  attacks  of  hoarseness  and  dyspncea. 
On  laryngoscopic  examination,  congestion  and  paralysis  in  abduction  of  the  left  vocal 
cord  vi'as  observed.  There  w^as  also  dulness  both  in  front  and  behind,  about  the  root  of 
the  lung.  I  had  the  advantage  of  a  consultation  with  2° Dr.  Quain,  and  the  affection  was 
diagnosed  to  be  due  to  enlarged  bronchial  glands  pressing  on  the  recurrent  nerve.  Under 
treatment  by  external  counter-irritation,  and  the  internal  administration  of  the  iodide  o^ 
iron,  the  patient  greatly  improved,  and  has  only  had  two  severe  relapses,  one  having 
occurred  six  years  after  she  first  came  under  notice,  though  there  has  always  been  some 
exacerbation  on  the  occurrence  of  catarrhal  or  general  debilitating  influences. 

Treatment. — Except  the  means  just  alluded  to  as  suitable  in 
scrofulous  and  simple  glandular  enlargements,  there  are  no  mea- 
sures likely  to  be  of  any  real  benefit,  though  tracheotomy  may 
give  relief  to  respiratory  distress  in  those  cases  in  w^hich  this 
symptom  is  manifested. 

PARALYSIS  OF  THE  SPHINCTERS  OF  THE  GLOTTIS— THYRO - 
ARYT^NOIDEI  (Fig.  98,  Plate  X.). 

It  is  the  fashion  now  to  consider  the  thyro-arytsenoidei 
as  tensors,  but  in  point  of  fact  these  muscles  have  above  all  other 
a  sphincter  action  of  the  glottis  proper,  in  which  function  they  are 
assisted  by  the  muscles  which  close  the  vestibule  or  supra-glottic 
portion  of  the  larynx.  Viewed  in  this  light  the  thyro-arytenoid 
muscles  may  be  regarded  as  either  tensors  or  laxors.  Gottstein, 
although  he  considers  that  the  thyro-aryttienoidei  act  as  tensors, 
expresses  just  my  view  when  he  says  that  their  function  is  to  give 
the  free  edges  of  the  vocal  cords  the  firmness  and  elasticity  (in 
other  words  tension  and  relaxation)  necessary  for  phonation. 
These  muscles  have  been  termed  constrictors  of  the  larynx,  and 
very  correctly  and  appropriately  also  the  vocal  muscles  (p.  18). 
When  they  are  paralyzed,  the  lower  notes  of  the  voice  are  impure 
or  lost,  a  condition  which  is  opposed  to  that  which  obtains  in 
the  case  of  paralysis  of  the  tensors  proper  (crico-thyroid).  A 
carefully  recorded  case  of  this  nature  is  contained  in  the  con- 
tribution of  Whitfield  Ward  to  Vvhich  I  have  previously  alluded. 
This  author  considers  the  action  of  the  thyro-arytaenoideus  to  be 
solely  that  of  a  laxor  of  the  cord.  It  is  doubtful  whether  the 
muscle  ever  acts  unilaterally,  or  whether  one-sided  paralysis  ever 
occurs.  Paralysis  of  the  internal  fibres  only  leads  to  loss  of 
falsetto  notes* 


NEUROSES  OF  THE  LARYNX. 


517 


The  cause  is  either  functional  over-exertion,  improper  voice- 
production,  or  hysteria.  There  is  generally  associated  inaction 
of  the  adductors,  and  this  complication  accounts  for  the  fact  that 
when  the  voice  is  restored  in  functional  aphonia  it  often  assumes 
a  peculiar  high-pitched  tone,  due  to  impairment  of  the  external 
fibres  of  the  thyro-arytenoid  muscles.  The  laryngoscope  reveals 
a  characteristic  elHptical  opening  on  phonation.  The  vocal  cords 
are  not  only  apparently  but  actually  thinner  than  when  the  muscle 
is  in  its  normal  condition.  Gottstein  also  mentions  what  I  have 
often  observed,  that  in  this  form  of  paralysis  there  is  increased 
approximation  of  the  ventrioular  bands,  even  to  the  extent  of 
contact,  and  that  this  condition  maybe  mistaken  for  inflammatory 
swelling. 

Another  paralysis  sometimes  associated  with  the  foregoing  is 
that  of  the  arytenoideus  proprius,  which  leads  to  a  double  ellip- 
tical or  hour-glass  shape  of  the  glottic  space  ;  the  central  con- 
striction being  produced  by  approximation  of  the  vocal  processes 
at  the  point  of  juncture  of  the  fibrous  and  cartilaginous  glottis 
(Fig.  100,  Plate  X.).  The  arytenoideus  may  be  also  separately 
paralyzed  (Fig.  gg,  Plate  X.).  Both  these  conditions,  especially 
the  last,  may  be  seen  in  acute  catarrh  ;  and  it  is  a  question 
whether  these  and  some  other  temporary  paralyses  may  not  be 
due  to  inflammation  of  the  small  glands  which  are  situated  around 
the  terminal  branches  of  the  recurrent  nerve. 

Prognosis  is  favourable  so  far  as  life  is  concerned,  because 
none  of  these  forms  of  paralysis  exercise  influence  on  respiration, 
but  in  long-standing  cases  the  hoarseness  may  be  obstinate. 

Treatment  consists  in  complete  functional  rest,  faradization, 
and  in  the  general  administration  of  remedies  calculated  to  reduce 
the  catarrh,  and,  later,  of  nervine  tonics.  On  recovery  careful 
vocal  instruction  will  do  much  to  prevent  a  relapse. 

SPASMODIC  AFFECTIONS. 

The  principal  spasms  of  the  larynx  are  those  of  the  tensors, 
constrictors,  and  adductors  of  the  vocal  cords,  of  which  the  latter 
is  by  far  the  more  important. 

SrASM  OF  THE  TENSORS  may  be  dismissed  in  a  very  few  words. 
It  has  already  been  alluded  to  in  association  with  chronic  pharyn- 
gitis and  with  motor  paralysis.  Attention  has  been  chiefly,  if  it 
was  not  primarily,  drawn  to  this  aftection  as  a  distinct  disorder 
by  Mackenzie,  who  defines  it  as  a  disease  '  causing  the  vocal  cords 
to  be  unduly  and  irregularly  stretched,  and  consequently  giving 


5i8  DISEASES  OF  THE  THROAT  AND  NOSE. 


rise  to  a  voice  which  is  feeble,  jerky,  unsteady,  and  constantly 
rising  to  a  high  key.' 

One  has  only  to  examine  deeper  into  the  symptoms  and  causes 
of  this  affection  to  feel  assured  that  the  want  of  co-ordination  in  the 
laryngeal  muscles  is  of  neither  neuropathic  nor  myopathic  origin, 
but  is  in  point  of  fact  the  result  of  improper  voice-production,  the 
patient  having  either  not  learned  how  to  breathe  when  speaking, 
or  else  having  spoken  after  the  lung  has  ceased  to  contain  enough 
air  to  keep  the  cords  in  regular  vibration.  It  is  thus  found 
amongst  the  very  class  of  speakers  subject  to  chronic  pharyngitis 
due  to  *  forcing  '  of  the  voice  ;  and,  indeed,  such  pharyngeal  disorder 
is  never  absent  from  those  labouring  under  spasm  of  the  tensors. 
So  far  from  its  being  very  rare,  I  consider  the  affection  in  its 
milder  forms  one  of  almost  everyday  occurrence. 

For  further  information  on  treatment,  etc.,  the  reader  is  re- 
ferred to  the  remarks  on  this  portion  of  the  subject  contained  in 
the  chapter  which  considers  pharyngeal  diseases  (pp.  198  and  225). 
It  is  quite  certain  that  no  such  case  can  be  cured  by  any  medicines, 
local  or  internal,  independently  of  pharyngeal  remedies  ;  nor  is 
faradization  of  the  least  service,  unless  it  be  accompanied  by  rest  to 
the  voice,  and,  on  resumption  of  its  use,  of  a  proper  elocutionary 
method  of  respiration.  On  the  other  hand,  if  these  latter  mea- 
sures be  adopted,  a  cure  may  with  confidence  be  promised,  and 
electrical  treatment  may  often  be  altogether  dispensed  with. 

The  condition  denominated  '  Chorea  of  the  Larynx  '  b}^  Mac- 
kenzie and  Schech,  and  '  Vocal  Asynergy '  by  Krishaber,  is  really 
of  the  same  nature,  due  to  the  same  causes,  and  amenable  to  the 
same  line  of  treatment.  In  as  much  as  it  represents  fatigue  and 
spasm  of  one  set  of  muscles  through  wrong  use  and  over-use  of 
another,  this  '  psellismus  laryngis  '  bears  some  analogy  to  the 
conditions  comprised  under  the  designation  of  '  writer's  cramp.' 
The  term  *  chorea  laryngis  '  has  also  been  applied  to  laryngeal 
manifestations  occurring  in  the  course  of  a  general  chorea  during 
the  first  periods  of  menstruation  and  of  puberty  in  the  male,  but 
this  affection  is  quite  distinct  from  that  under  consideration. 

Spasm  of  the  adductors,  that  of  the  tensors  being  dismissed 
from  further  consideration,  may  be  better  described  under  the 
broader  term,  spasm  of  the  glottis,  and  implies  a  spastic  dis- 
turbance of  automatic  muscular  movements  of  the  larynx,  of 
varying  duration,  from  a  few  seconds  to  at  most  a  few  minutes. 
The  particular  act  which  is  disturbed  is  that  of  inspiration, 
during  which  there  is  convulsive  adduction  of  the  vocal  cords, 
causing  a  narrowing  of  the  glottic  space  at  the  moment  when  it 
should  be  wndest.    This  is  the  condition  commonly  recognised  as 


NEUROSES  OF  THE  LARYNX. 


519 


laryngismus  stridulus,  and  is  the  only  one  to  which  the  term 
false  croup  should  be  applied. 

Etiology. — The  disease  is  essentially  one  of  childhood,  or 
rather  of  infant  life,  and  occurs  most  frequently  between  the  ages 
of  four  months  and  two  years  ;  but  it  is  occasionally  seen  in 
children  up  to  the  age  of  seven  or  eight  years.  The  male  sex  is 
more  liable,  in  the  proportion  of  at  least  two  to  one.  Until  quite 
recently  the  causes  of  this  affection  were  but  imperfectly  under- 
stood. It  is  now  agreed,  however,  that  there  is — if  not  an 
hereditary — a  decided  family  predisposition  to  this  spasmodic 
affection  ;  that  the  majority  of  patients  are  either  the  subjects  of 
rachitis  or  disposed  to  that  condition,  the  fontanelles  being  open, 
and  the  skull-cap  and  thorax  unusually  compressible  ;  that  the 
disease  occurs  most  frequently  in  cold  climates,  in  cold  seasons,  and 
in  unfavourable  hygienic  surroundings,  and  that  reflex  irritation 
from  entozoa  or  from  mal-assimilation  of  food  plays  also  an 
important  part. 

In  my  opinion  this  last  cause  is  of  greater  importance  than  is 
generally  admitted,  for,  given  the  other  predisposing  causes,  the 
presence  of  even  a  comparatively  small  atom  of  indigestible 
material  will  excite  to  an  attack ;  such,  for  instance^  as  the 
currant  from  a  bun,  a  raisin  or  a  grape-skin,  or  a  pip-stone  of 
these  last-named  fruits.  It  is  clear,  therefore,  that  the  peripheral 
irritation  of  the  pneumogastric,  either  in  its  laryngeal,  pulmonary, 
or  gastric  branches,  is  a  frequent  factor. 

Enlargement  of  the  thymus  gland  was  considered  by  ^^^opp  to 
be  the  principal  cause  of  laryngeal  cramp  in  children,  an  opinion 
which  did  not  bear  further  examination  so  far  as  to  its  being  any- 
thing like  a  universal  cause  ;  but  many  irrefragable  cases  have 
been  reported  in  which  post-mortem  examination  showed  thymic 
glandular  pressure  on  the  recurrent  to  have  been  the  cause  of 
death.  It  is  here  thrown  out  as  a  suggestion,  the  truth  of  which 
can  only  be  confirmed  or  dispelled  by  further  experience,  that,  in 
the  cases  of  young  girls  subject  to  glottic  spasm,  there  is  a  pre- 
dominating predisposition  to  thyroid  congestion,  and  to  either 
direct  or  to  sympathetic  nerve-irritation. 

Such  a  predisponent  is  somewhat  in  consonance  with  that  of 
Hughlings  Jackson,  that  laryngismus  is  a  perversion  of  the 
ordinary  respiratory  rhythm  due  to  medullary  supervenosis,  and 
equally  applicable  to  the  condition  which  brings  about  laryngeal 
and  epileptiform  nasal  neuroses.  This  view,  as  well  as  every 
other  hitherto  advanced,  has  recently  received  uncompromising- 
opposition  from  William  Gay,  who,  in  a  recent  number  of  Brain, 
proffers  an  alternative  theory  that  laryngismus  is  in  fact  a  re- 


520 


DISEASES  OF  THE  THROAT  AND  NOSE. 


spiratory  convulsion,  the  point  of  departure  of  which  is  that 
portion  of  the  centre  which  presides  over  the  adductors  of  the 
vocal  cords ;  and  he  compares  this  spasm  to  other  physical  ex- 
pressions of  emotion,  such  as  blushing,  desire  to  micturate  through 
fear,  etc. ;  while  the  frequency  of  attacks  during  sleep  is  explained 
on  the  hypothesis  that  the  spinal  centres  are  then  less  fully  con- 
trolled, and  are  rendered  more  susceptible  to  reflex  or  quasi-reflex 
influences.  It  need  only  be  added  that  acceptance  of  these  care- 
fully considered  theories  by  no  means  dismisses  the  co-operative 
importance  of  many  of  those  peripheral  causes  which  have  long 
been  conceded. 

Amongst  these  there  remains  to  be  noted  one  other  factor  of 
probably  greater  primary  importance  than  any  of  the  foregoing, 
namely,  the  presence  of  naso-pharyngeal  glandular  hypertrophy; 
in  other  words,  adenoid  growths  in  the  vault  of  the  pharynx. 
These  vegetations,  by  blocking  the  natural  breathway  of  the  nose 
and  causing  the  patient  to  always  breathe  with  open  mouth,  are 
probably  present  in  the  majority  of  children  subject  not  only  to 
laryngismus,  but  also  to  tetany  and  convulsions,  which  are  both 
but  exaggerated  examples  of  the  same  disease.  They  may  reason- 
ably be  held  to  account  not  only  for  the  liability  to  exacerbations 
in  cold  and  damp  weather,  but  also  for  any  or  all  of  the  reflex 
symptoms  in  the  track  of  the  pneumogastric  nerve. 

22Mantle  has,  on  the  experience  of  one  case,  expressed  the 
opinion  that  a  relaxed  uvula  is  a  frequent  cause  of  laryngismus, 
but  it  is  probable  that  in  all  cases  the  paresis  of  the  soft  palate, 
which  causes  the  elongation  of  the  uvula,  is  always  secondary  to 
the  presence  of  adenoid  vegetations  or  enlarged  tonsils,  for  in  my 
own  practice  I  have  found  that  when  these  growths  are  removed, 
the  muscular  contractility  of  the  soft  palate  of  a  young  child  is 
usually  quickly  restored. 

Spasm  of  the  glottis  occurs  in  adults  under  tw^o  circumstances : 
— I.  In  females,  chiefly  at  the  age  of  puberty  ;  2.  From  traumatic 
causes,  to  which  some  allusion  has  been  made  in  the  chapter  on 
^  Benign  Neoplasms.'  This  includes  also  the  irritation  of  certain 
noxious  gases  and  the  false  passages  of  fluid  or  solid  substances. 
It  may  further  be  the  result  of  faulty  voice-production  or  other 
cause  for  varix  of  the  vessels  at  the  base  of  the  tongue,  and  hyper- 
trophy of  the  lingual  tonsil,  and  may  then  be  represented  by  a 
species  of  tenesmus,  similar  to  what  is  often  observed  under 
similar  circumstances  in  the  fauces  and  pharynx. 

Symptoms. — The  peculiar  sj-mptoms  of  this  disease,  which 
have  given  rise  to  the  terms  child-crowing,  laryngismus  stridulus, 
and  false  croup,  are  too  well  known  to  need  detailed  description, 


NEUROSES  OF  THE  LARYNX. 


521 


and  may  be  found  recounted  in  any  work  on  general  medicine. 
It  is  only  necessary  to  remind  the  reader  that  the  suddenness  and 
shortness  of  the  attack,  and  the  absence  of  signs  of  inflammation, 
differentiate  this  affection  from  true  croup  ;  also,  that  very  slight 
attacks,  especially  when  occurring  during  the  day,  are  apt  to  pass 
unnoticed.  Any  child,  therefore,  whose  frame  and  family  history 
predispose  to  the  complaint  should  be  most  carefully  watched,  if 
the  least  disposition  be  manifested  to  catch  the  breath  during  the 
excitement  of  play  or  of  so-called  *  passion,'  which  is  often  a  mis- 
construed evidence  of  convulsion.  The  alarmingly  sudden  ter- 
mination of  this  disease  might  be  often  averted  were  mothers 
forewarned  to  observe  these  slight  indications. 

Treatment. — In  the  case  of  children,  cod-liver  oil,  the  phos- 
phates of  iron  and  lime,  iodide  of  iron,  etc.,  are  indicated  for 
systematic  administration.  Small  does  of  chloral,  or  of  bromide 
of  potassium,  may  be  given  at  night,  but  especial  regard  must  be 
had  to  the  form  of  nutriment  administered,  particularly  if  the 
child  be  brought  up  by  hand.  During  an  attack,  the  importance 
of  placing  the  child  in  the  sitting  posture,  or  of  bending  the  body 
forward,  slapping  the  back,  and  the  administration  of  hot  baths 
with  cold  affusions  to  the  head,  etc.,  are  all  well  known.  Whether 
or  not  the  act  of  dentition  be  an  exciting  cause  to  an  attack, 
lancing  of  the  gums  gives  undoubted  relief  even  in  cases  where  no 
tooth  appears  to  be  pressing  to  eruption.  Scammony,  which  is 
deservedly  such  a  favourite  remedy  in  these  spasmodic  laryngeal 
attacks  in  children,  is  of  general  service  as  an  aperient,  and  of 
special  utility  as  a  vermifuge.  Adenoid  vegetations  are  to  be 
sought  for  in  all  cases,  and  when  present  are  to  be  promptly 
removed,  as  described  further  on,  in  Chapter  XXV. 

In  young  girls,  the  indications  must  be  to  establish  the  men- 
strual function,  and  to  treat  actively,  by  local  measures,  any 
thyroid  congestion  or  enlargement.  In  traumatic  spasm,  trache- 
otomy is  often  called  for;  and  this  extreme  step  is  sometimes 
necessary  in  those  troublesome  hysterical  cases  which  occasionally 
come  under  notice  as  occurring  in  females  about  middle  life. 

NERVOUS  LARYNGEAL  COUGH. 
This  form  of  laryngeal  neurosis  has  been  considered  by  some 
authors  separately  from  the  spasm  of  childhood  on  the  one  hand, 
and  of  females  in  connection  with  the  occurrence  or  cessation  of 
menstruation  on  the  other ;  and  also  without  knowledge,  or,  at 
least,  recognition  of  the  circumstance,  that  when  the  so-called 
nervous  cough  is  not  manifested  in  such  association,  there  are 


S22 


DISEASES  OF  THE  THROAT  AND  NOSE. 


almost  always,  if  not  universally,  other  neurosal  symptoms.  These 
will  be  more  properly  considered  under  the  head  of  reflex  epilep- 
tiform neuroses. 

^^Morell-Mackenzie,  who  treats  of  the  condition  as  a  distinct 
affection,  employs  the  term  '  to  describe  a  shrill,  often,  indeed, 
extremely  metallic  cough,  which,  in  the  entire  absence  of  any 
laryngeal  or  pulmonary  affection,  occurs  in  paroxysms,  and  lasts 
for  many  hours  each  day,  only  ceasing  when  the  patient  sleeps  at 
night.  The  cough  has  a  very  peculiar  and  even  startling  sound, 
being  often  deep  and  vibrating,  or  even  occasionally  resembling 
the  barking  of  a  dog  or  the  quacking  of  a  duck.' 

My  own  impression  is,  that  there  is  always  an  objective  reason 
for  such  a  condition.  Of  these,  the  irritation  of  enlarged  tonsils 
— of  which  I  have  mentioned  three  instances  (p.  25.4) — is  the 
commonest  in  children.  It  may  also  probably  be  a  reflex  mani- 
festation of  ovarian  irritation  in  young  girls,  and  in  these  cases 
there  is  almost  always  congestion  or  enlargement  of  the  thyroid 
gland.  The  condition  is  aggravated  at  the  menstrual  epoch,  and 
relieved  on  its  termination.  Dysmenorrhoea  is  usually  present. 
I  have  seen  one  case  of  nervous  laryngeal  cough  which  always 
occurred  in  the  early  days  of  conception,  and  came  to  be  regarded 
as  a  certain  prognostic  of  pregnancy  before  other  circumstances 
confirmed  it.  The  symptom  disappeared  at  the  period  of  '  quick- 
ening.' 

This  form  of  cough  is  also  associated  with  lingual  and  pharyn- 
geal varix.  Another  etiological  factor  is  peripheral  irritation 
of  the  superior  laryngeal  nerve,  which  is  induced  by  changes  of 
weather,  particularly  cold  north-east  and  east  winds,  and  is 
characterized  by  a  distinct  and  constant  localization  at  some  one 
spot  of  the  pharyngo-laryngeal  cavity.  This  area  can  generally  be 
seen  with  the  mirror  to  be  the  subject  of  limited  congestion.  Of 
this  I  have  had  two  instances  in  my  practice : 

One  is  that  of  a  lady,  now  about  55,  who  has  applied  to  me  once  or  twice  a  year  for 
the  last  sixteen  or  seventeen  years ;  another,  also  a  lady,  now  45  years  old,  who  is  laid  up 
nearly  as  often,  and  requires  visiting  at  her  own  house.  She  has  been  under  observation 
for  about  seven  years.  Whenever  one  comes  I  am  sure  to  be  called  for  by  the  other,  and 
I  can  foretell  almost  with  certainty  when  to  expect  that  my  aid  will  be  sought.  In  neither 
is  there  either  bronchitis  or  laryngitis,  but  there  is  always  slight  temporary  paresis  of  the 
ccrd  of  the  affected  side,  which  in  each  case  is  the  right.  I  have  searched  for  adhesions 
of  the  pleura,  enlarged  glands,  or  other  possible  extra-laryngeal  cause,  but  without  success. 
In  one  thing  my  patients  are  agreed,  namely,  that  they  '  swear  by  the  brush,'  that  is,  the 
local  applications  of  chloride  of  zinc  (Form.  65)  or  other  mineral  astringent,  to  the 
affected  part.  Combined  with  this  treatment,  expectorant  pills  (Form.  103)  and  lozenges 
(Form  18)  aid  the  temporary  cure,  which  occupies  generally  from  ten  days  to  two  or 
three  weeks 


NEUROSES  OF  THE  LARYNX. 


523 


REFLEX  EPILEPTIFORM  NEUROSES  OF  THE  LARYNX. 

Synonyms. — Laryngeal  vertigo  ;  Laryngeal  epilepsy  ;  Complete 
glottic  spasm  in  adults. 

Remarks  on  the  neuroses  of  the  larynx  would  not  be  complete 
without  reference  to  the  curious  affection  variously  known  under 
the  above  names.  Attention  was  first  prominently  called  to  the 
subject  by  a  communication  of  ^^Lefferts,  in  1883,  who,  giving 
two  cases  in  his  own  practice,  added,  as  is  his  custom,  an  excellent 
resume  of  the  subject  up  to  date.  The  affection  had  first  been  de- 
scribed in  1876  by  ^^Charcot,  and  this  author  had,  up  to  the  year 
"•^1879,  observed  four  cases.  ^"Gasquet,  ^^Krishaber,  and  ^^Gray 
have  each  recorded  a  case ;  and  since  the  article  of  Lefferts  two 
more  have  been  added,  one  by  ^^McBride,  the  other  by  ^^Russell. 
Still  more  recently  ^'^Massei  has  added  three,  and  ^^Knight  two 
cases.  Almost  all  these  authors  have  taken  the  opportunity  of 
the  publication  of  their  cases  to  add  valuable  information  on  the 
etiology  and  character  of  the  malady.  The  contributions  of 
McBride,  Gray,  and  Knight  are  specially  valuable  in  this  respect. 
I  shall  presently  give  brief  notes  of  three  unequivocal  instances 
in  my  own  practice,  which  brings  up  the  number  to  nineteen ;  and 
I  have  seen  a  few  others  in  which  the  symptoms  did  not  go  the 
length  of  vertigo  or  epilepsy,  but  presented  several  modified 
features  common  to  such  conditions. 

I  have  not  included  an  interesting  example  in  the  practice  of  ^'^Sommerbrodt,  of  re- 
carrent  loss  of  consciousness  attended  by  convulsions,  due  to  the  presence  of  an  intra- 
laryngeal  tumour.  That  the  symptoms,  which  were  without  doubt  closely  allied  to  those 
of  genuine  epilepsy,  were  caused  by  the  reflex  of  the  polyp,  is  proved  by  the  fact  that 
ihey  disappeared  at  once  after  its  removal. 

Laryngeal  neuroses  of  the  nature  of  vertigo  are  not,  so  far  as 
my  reading  goes,  mentioned  in  any  systematic  work  on  Diseases 
of  the  Throat  up  to  the  present  time,  except  by  way  of  appendix 
to  McBride's  translation  of  Gottstein ;  nor  is  there  any  remark 
on  the  subject  by  either  Brown-Sequard  (Epilepsy),  or  Stephen 
Mackenzie  (Vertigo),  in  the  articles  on  those  diseases  in  Quain's 
Dictionary.  Seeing,  however,  as  Russell  remarks,  that  attacks  of 
unconsciousness  attending  a  violent  cough  are  not  unknown  to 
medical  men,  it  seems  not  improbable  that  if  the  immediate 
precursors  of  the  attack  be  carefully  noted,  this  form  of  laryngeal 
neurosis  may  prove  to  be  not  so  infrequent  as  hrs  hitherto  been 
thought.    In  this  belief  we  are  corroborated  by  Knight. 

Etiology. — Predisposing  Causes. — From  an  analysis  of  the 
cases  at  present  on  record,  and  including  my  own — nineteen  in  all 
— three  presented  neurotic  predisposition,  viz.,  *  incomplete  history 
of  hereditary  neurosis  ;'  *  a  sister  decidedly  neurotic  ;*  and  *  a 


524 


DISEASES  OF  THE  THROAT  AND  NOSE. 


decidedly  nervous  constitution,'  representing  the  extent  of  this 
factor.  In  one  other  the  patient  *  had  been  for  a  considerable 
time  under  great  mental  strain  in  the  direction  of  enormous 
financial  matters  through  very  troublous  times.'  In  one  case 
the  patient's  disposition  to  attacks  were  increased  by  '  over- 
indulgence in  stimulants ;  for  although  not  an  habitual  drunkard, 
he  sometimes  drank  to  excess.'  In  the  first  of  my  cases,  the 
patient's  occupation  as  a  w^ine-merchant  doubtless  increased  his 
liability ;  and  in  the  third  the  same  predisposing  influence 
existed.  In  one  of  the  milder  cases,  to  which  I  have  alluded, 
over-indulgence  in  the  pleasures  of  the  table — but  rather  of  food 
than  of  drink — wa.s  acknowledged.  I  can  also  recall  another 
instance  which  occurred  to  me  many  years  ago,  and  presented 
very  similar  symptoms.  The  patient,  who  was  a  traveller  for  a 
firm  of  whisky  distillers,  had  violent  attacks  of  cough — became 
very  turgid,  and  often  feared  suffocation.  He  only  lost  his  trouble 
on  changing  his  occupation.  As  to  other  predisponents,  gent  or 
rheumatism  are  mentioned.  In  only  one  case  is  there  note  of  a 
syphilitic  history.  The  primary  attack  had  occurred  when  the 
patient  was  25 ;  he  had  married  at  22,  and  his  eldest  child  was 
of  sound  constitution. 

In  some  instances  a  chronic  laryngitis,  bronchitis,  asthma,  a 
catarrhal  pneumonia  with  irritation  at  the  right  apex,  or  other 
chest  affection,  had  existed  for  years  or  months  antecedent  to  the 
first  attack. 

As  to  sex,  all  the  cases  reported  up  to  now,  with  but  one  ex- 
ception (a  widow  aged  47),  have  been  males ;  and  as  to  the  age, 
the  youngest  is  35,  and  the  oldest  70.  The  average  period  of 
Hfe,  in  the  fifteen  cases  in  which  the  age  is  stated,  at  which  the 
patient  came  under  observation,  is  rather  over  52  years.  The 
average  of  first  manifestation  would  appear  to  be  from  40  to  45. 

Of  the  exciting  causes,  peripheral  irritation  of  the  larynx  is 
almost  universally  observed.  In  one  case  the  traumatism  of  a 
fish-bone  accidentally  swallowed  was  the  starting-point.  In 
another,  the  spasm  occurred  during  a  meal.  In  one  instance  the 
first  attack  followed  violent  emotion  ;  the  second,  on  sudden 
noise ;  and  a  third,  lear  of  collision  when  in  a  steamer.  In 
another,  the  first  attack  occurred  after  a  day  of  great  worry  and 
fatigue.  In  one  of  my  own  cases  a  pinch  of  snuft'  resulted,  on 
two  separate  occasions,  in  an  instantaneous  attack.  Tobacco 
smoke  w^ould  also  cause  seizure  in  this  patient,  and  the  same 
circumstance  induced  it  in  Krishaber's  case. 

Symptoms. — Discontinuing  analysis  of  each  separate  case  or 


NEUROSES  OF  THE  LARYNX. 


symptom,  but  generalizing  from  all,  the  following  may  be  con- 
sidered a  fair  composite  picture  of  the  more  prominent  features  of 
the  malady. 

As  a  rule  the  patient  experiences,  by  way  of  premonition,  a 
sensation  of  burning,  heat,  tickling,  or  '  squeezing  '  of  the  larynx ; 
while  in  many  there  is  no  such  slight  warning,  in  others  there  is 
distinct  spasm.  Then  comes  invariably  a  cough,  sometimes  in 
paroxysm,  sometimes  sharp,  short,  and  dry,  and  this  cough  is 
followed  immediately  by  giddiness.  This  giddiness  may  or  may  not 
be  followed  by  absolute  loss  of  consciousness.  In  far  the  majority 
of  cases  it  is  so,  and  in  a  few  others  there  is  a  distinct  convulsion. 
In  Charcot's  third  case  *  the  patient  experienced  giddiness,  and 
almost  at  the  same  time  the  fingers  of  the  left  hand  became  flexed, 
the  left  arm  became  stiff  in  the  position  of  extension,  and  was 
raised  almost  as  high  as  the  head,  while  the  whole  limb  gave 
three  or  four  convulsive  twitches.'  In  my  second  case  there  was 
occasionally  great  pain  with  rigidity  from  the  shoulder,  which 
extended  down  the  inner  side  of  the  upper  arm  and  forearm,  along 
the  course  of  the  radial  nerve  to  the  thumb,  and  this  symptom, 
accompanied  by  general  tremor,  was  always  induced  if  I  placed  a 
laryngeal  mirror  in  his  throat,  or  a  nasal  speculum  in  his  nostrils. 
In  no  instance  is  there  record  of  biting  of  the  tongue,  or  foaming 
at  the  mouth ;  nor  is  there  once  recorded  a  sign  of  the  cry 
characteristic  of  epilepsy.  But  in  two  cases  there  was  stridor,  in 
one  slight,  in  another  *  like  the  last  paroxysm  of  whooping- 
cough.'  One  patient  injured  himself  once  in  falhng,  but  it  is  the 
only  instance  recorded  of  such  an  accident. 

Habitual  hebetude,  mental  clouding,  confusion,  or  other 
symptoms  of  cerebral  disorder,  is  not  witnessed,  or  only  in  a 
slight  degree ;  but  loss  of  memory  is  noted  by  one  author,  and  was 
a  spontaneously  mentioned  symptom  by  two  of  my  patients. 
The  frequency  of  the  attacks  varies  greatly.  One  of  Charcot's 
patients  had  fifteen  or  sixteen  a  day,  and  one  of  mine,  seven  or 
eight.  On  the  contrary,  the  second  of  my  patients  had  very  infre- 
quent seizures,  with  intervals  of  remission  of  many  years,  the  first 
attack  dating  thirty  years  back.  The  dttration  of  the  '  fit '  is  very 
short,  and  the  recovery  as  a  rule  so  complete,  that  the  patient 
resumes  his  meal,  occupation,  or  conversation  immediately.  The 
record  of  objective  symptoms  is  very  incomplete,  and  is  often 
omitted.  Some  hypersemia  of  the  larynx,  or  congestion,  with 
granular  pharyngitis,  is  the  most  that  has  been  generally  noted ; 
while  in  one  or  two  instances  chronic  bronchitis,  and  in  one  the 
presence  of  emphysema,  have  been  specially  mentioned.  The 
physical  evidence  that  I  have  particularly  remarked,  not  only 


526 


DISEASES  OF  THE  THROAT  AND  NO^E. 


in  these  three  pronounced  cases,  but  in  others  of  obstinate 
paroxysmal  cough  without  actual  vertigo,  has  been  a  distinct  and 
considerable  degree  of  varix  of  the  base  of  the  tongue  and  upper 
part  of  the  larynx,  with  a  corresponding  hyperaemia  of  the  nares. 
I  have  for  so  many  years  urged  that  capillary  venous  engorgement 
is  the  cause  of  granular  pharyngitis,  that  I  can  readily  explain  the 
association  of  this  last  condition  with  the  cases  reported  by  other 
observers  ;  and  I  suspect  that  some  form  or  other  of  varix  in  the 
pharyngeal  and  naso-pharyngeal  regions  would  be  almost  always, 
if  not  invariably,  found  when  looked  for,  and  that  in  many  cases 
considered  as  instances  of  purely  laryngeal,  or  purely  nasal  reflex, 
the  association  of  the  two  will,  in  the  future,  be  more  frequently 
recognised.  I  have,  indeed,  no  doubt  that  in  many  cases  of  aural 
vertigo  also,  nasal  or  pharyngeal  hypersemia  is  more  frequently  a 
concomitant  symptom  than  is  recorded.  That  all  or  any  of  these 
conditions  may  and  are  often  the  result  of  a  fault  in  the  systemic 
circulation,  I  readily  admit ;  but  I  am  equally  convinced  that  the 
special  circumstances  of  their  localization  require  to  be  reckoned 
with  in  connection  with  treatment.  Before  proceeding  further  I 
will  relate  my  cases : 

Case  i. — Mr.  T. ,  aged  6i,  a  wine-merchant,  was  seen  by  me  in  consultation  with 
Dr.  Keele,  of  Islington,  on  November  30,  1886.  He  complained  that  for  three  years  he 
had  suffered  every  winter  from  irritation  at  the  top  of  the  throat,  but  he  had  got  well  in 
the  summer. 

So  long  ago  as  thirty  years  previously  he  had  suffered  from  giddiness  while  sr  loking  a 
cigar,  the  smoke  seemed  to  have  gone  the  wrong  way  ;  this  made  him  cough,  and  he 
fell  down  immediately  after,  in  an  absolutely  unconscious  state.  Since  then  he  had  not 
smoked,  and  he  now  dreaded  the  atmosphere  of  tobacco,  as  it  always  predisposed  to,  if  it 
did  not  induce,  an  exacerbation.  On  and  off,  at  intervals  of  even  years,  he  had  had 
repetitions  of  these  attacks  of  cough,  followed  by  giddiness  and  unconsciousness,  and 
once,  four  or  five  years  before,  a  pinch  of  snuff  had  caused  him  to  '  drop  on  the  floor  dead 
in  a  minute.'  He  was  then  reminded  of  the  circumstance  previously  forgotten,  that  snuff 
had  induced  a  milder  attack  of  the  same  nature  once  before. 

Two  years  previously  he  had,  on  leaving  a  tram-car  at  the  corner  of  his  street,  dropped 
insensible  on  the  kerb.  He  had  been  hurried  in  crossing  to  the  pavement,  and  remem- 
bered that  he  had  a  catch  in  his  breath,  with  cough,  before  he  fell. 

The  patient  was  an  apparently  healthy  man,  though  rather  florid  in  colour,  and  inclined 
to  make  himself  an  invalid,  so  much  did  he  dread  exposure  to  cold  or  any  inclemency  of 
weather.  His  chest  was  healthy,  and  his  heart  sounds  fairly  good,  though  the  action  was 
somewhat  slow.  On  looking  into  his  throat  I  saw  that  his  uvula  had  been  reduced,  and, 
as  he  said,  with  advantage.  Proceeding  downwards  I  then  observed  in  the  mirror  slight 
congestion  of  his  larynx  ;  but  above  all,  there  was  extreme  varix  of  the  base  of  the  tongue, 
and  of  the  lingual  surface  of  the  epiglottis.  He  said  that  he  had  been  a  fairly  temperate 
man,  but  that  in  the  exercise  of  his  vocation  he  had  '  tasted '  a  great  deal.  He  had 
discovered  that  his  symptoms  were  always  worse  after  such  occasions.  I  recommended 
astringents,  and  later  destruction  of  the  varicose  veins.  I  recently  heard  from  Dr.  Keele 
that  he  derived  undoubted  benefit  from  my  advice,  but  he  has  not  yet  summoned  courage 
to  undergo  an  attempt  at  a  more  radical  cure. 

Case  2. — Mr.  William  C,  aged  62,  from  Retford,  consulted  me  on  October  20,  1886, 
with  the  following  history  : 


NEUROSES  OF  THE  LARYNX. 


527 


He  stated  that  six  or  seven  years  previously  he  had  first  been  attacked  with  cjiddineps, 
which  would  cause  him  to  fall  insensible,  and  that  this  would  occur  seven  or  eiyht  times 
in  one  day.  He  had  not  at  first  noticed  that  these  attacks  were  always  preceded  by  a 
cough,  though  he  had  long  been  aware  of  irritation  in  his  throat,  but  as  time  went  on  the 
association  was  noted  to  be  invariable.  He  described  his  sensations  when  unconscious  as 
'  most  delightful.'  There  was  a  tickling  in  the  throat,  a  slight  cough,  and  then  a  hardly 
more  than  momentary  but  complete  loss  of  consciousness,  which  he  found  most  calming  to 
himself,  though  it  was  of  course  a  very  terrifying  matter  for  his  wife  and  children.  He 
personally  had  not  become  frightened  till  he  found  he  could  not  walk  straight,  and  had 
to  hold  on  to  railings  or  to  someone's  arm  to  prevent  his  reeling.  Once  or  twice  his 
gait  had  led  to  the  formation  of  unjust  suspicions  as  to  his  sobriety. 

About  the  year  1882  he  had  been  under  the  care  of  another  throat  specialist,  and  having 
undergone  a  long  course  of  insufflations,  with  only  a  slight  alleviation,  derived  immediate 
benefit  on  his  uvula  being  cut.  For  a  short  time  there  was  a  complete  cessation  of  his 
attacks,  and  though  they  soon  returned,  he  had  not  since  the  operation  had  more  than  one 
a  day.  A  new  symptom  had  developed,  namely,  intense  headache  between  the  brows  on 
the  slightest  cough,  accompanied  by  a  pain  and  rigidity  in  the  shoulder,  which  extended 
down  the  right  arm  to  the  thumb. 

The  patient  was  rather  markedly  pale  in  complexion,  but  as  far  as  could  be  ascertained, 
free  from  organic  disease. 

On  examining  his  nares,  I  found  enlargement  and  hypersemia  of  both  inferior  tur- 
binated bones,  with  increased  congestion  of  the  left  middle  turbinated  bone,  and  of  the 
left  nostril  generally.  At  the  base  of  the  tongue  there  was  a  large  congery  of  varicose 
veins,  with  some  haemorrhoidal  prominences.  This  condition  also  was  worse  on  the  right 
side.    There  was  some  dyspepsia,  but  otherwise  fair  general  health. 

The  following  was  the  treatment :  Destruction  of  the  veins  by  the  galvano-cautery, 
searing  of  the  nostrils  also  by  the  same  process,  administration  of  an  alkaline  tonic 
(Form.  97),  use  of  vaseline,  with  cocaine  and  eucalyptus  oil,  to  the  nostrils,  and  employ- 
ment for  several  hours  a  day  of  an  oro-nasal  inhaler,  containing  ozonic  ether  and  pine  oil 
^Form.  41).  Fie  made  great  improvement,  and  after  three  months  reported  that  he  had 
not  had  one  fit ;  but  though  the  headache  had  been  less,  it  was  not  entirely  relieved.  I 
found  all  the  veins  had  not  been  destroyed  ;  the  cautery  was  therefore  again  repeated 
(recently),  with,  so  far  as  can  be  seen,  further  marked  benefit  to  his  symptoms. 

Case  3. — Dr.  ,  aged  42,  consulted  me  recently  on  account  of  giddiness — which  he 

carefully  distinguished  from  a  mere  dizziness — that  occasionally  arose  when  he  sneezed, 
coughed,  or  blew  his  nose  with  the  least  increase  of  vigour.  He  stated  that  he  always 
had  a  premonition  of  an  attack,  and  had  acquired  the  precautionary  habit  of  holding  on 
to  a  chair  or  other  support  when  about  to  cough  or  sneeze.  He  had  distinct  confusion, 
and  a  feeling  of  cerebral  tension  ;  but  had  only  once — twenty  years  ago — been  absolutely 
unconscious. 

Lately,  attacks  of  sneezing  had  been  more  frequent,  and  he  had  also  suffered  from 
nocturnal  dyspnoea,  which  he  considered  of  the  nature  of  asthma.  The  patient  had 
practised  for  twenty  years  in  a  poor  neighbourhood  of  London.  As  a  student  in  Dublin 
he  had  drunk  rather  hard,  and  on  coming  to  town  had  taken  freely  of  beer,  though  he  had 
abjured  spirits.  Since  a  previous  consultation  with  rae  two  years  ago,  he  had  been  almost 
an  abstainer.  The  ]3resent  local  condition  was  one  of  hyperaemia  of  the  turbinated  bones, 
an  exceedingly  relaxed  uvula,  and  varix  at  the  base  of  the  tongue.  The  treatment  adopted 
was  similar  to  that  in  the  last  case.    It  is  too  early  to  speak  of  result. 

There  has  been  much  speculation  on  the  nature  of  this  neurosis. 
Charcot  beHeves  that  the  ori.s^in  of  the  symptoms  incident  to  the 
affection  Hes  in  a  pecuhar  irritation  of  the  centripetal  laryngeal 
nerves  ;  that  the  laryngeal  neurosis  is,  in  many  respects,  to  be 
compared  with  the  aural  vertigo  met  with  in  Meniere's  disease. 


528 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Gray  first  suggested  that  whereas  in  the  laryngeal  malady  there 
is  almost  always  unconsciousness  in  addition  to  vertigo,  the 
former  symptom  is  wanting  in  the  auditory  affection.  It  is  to  be 
added  that  in  aural  vertigo  there  is  a  more  real  disturbance  of 
locomotor  co-ordination  than  what  is  generally  seen  in  the  laryn- 
geal analogue.  In  my  second  case,  however,  locomotion  was 
distinctly  and  consciously  disordered,  and  in  a  minor  degree  in 
the  third.  The  same  feature  was  observed  in  Krishaber's  case. 
McBride  rejects  Gray's  view,  that  the  neurosis  is  rather  of  the 
nature  of  an  epilepsy  than  a  vertigo,  because  consciousness  was 
not  completely  lost  in  every  instance.  It  certainly  was,  however, 
in  the  majority.  The  same  might  be  said  with  regard  to  muscular 
contractions.  There  is  an  admitted  laryngeal  spasm  in  everv 
case,  but  in  a  few  only  similar  manifestations  in  the  limbs.  In 
McBride's  patient  there  was  exaggerated  tendon  reflex,  ankle 
clonus,  spasmodic  contractions  of  the  palatal  muscles,  and  occa- 
sionally spasmodic  stricture  of  the  gullet.  In  answer  to  this 
objection  of  McBride,  the  following  remarks  of  ^^Brown-Sequard 
on  general  epilepsy  are  very  much  to  the  point : 

*  Of  these  two  features— muscular  spasm  and  loss  of  consciousness — neither  is  alone 
sufficient  to  establish  the  existence  of  epilepsy.    Still  each  of  these  two  kinds  of  symptoms 

when  occurring  in  the  form  of  an  attack,  is  an  epilepiiform  manifestation  Two 

patients,  who  were  brother  and  sister,  were  incompletely  epileptic  ;  one  had  only  attacks 
of  convulsions,  the  other  only  attacks  of  loss  of  consciousness.  Their  father  had  been 
completely  epileptic,  and  one  of  these  two  young  patients  had  inherited  one  aspect  of  the 
disease,  the  other  the  other  aspect.' 

Again,  Russell  Reynolds  states  that  he  has  seen  attacks  of 
pdH  mat  with  no  other  symptom  than  a  loss  of  consciousness,  and 
Brown-Sequard  on  this  point  says  : 

'  therefore  we  must  admit  that  sometimes  a  pure  and  simple  loss  of  perception  is  all  that 
exists  in  a  seizure  of  epilepsia  mitior.'' 

For  my  own  part,  I  do  not  see  how  one  can  escape  the  conclu- 
sion that  the  condition  we  are  considering  has  more  in  common 
with  the  milder  forms  of  epilepsy  than  with  simple  vertigo,  and 
with  the  greatest  deference  for  his  opinion,  it  is  difficult  to  under- 
stand how  Charcot,  in  classing  the  affection  as  a  vertigo,  over- 
looked the  convulsive  symptoms  in  his  third  case,  which  have 
been  already  quoted.  The  movement  of  the  arm  in  his  patient, 
and  the  pain  and  rigidity  in  the  shoulders  and  along  the  arm  in 
mine,  strikingly  call  to  mind  Brown-Sequard's  remark  that 

*in  cases  of  epilepsy  due  to  organic  cerebral  disease,  or  to  cerebral  congestion  (much 
more  rarely  in  other  cases),  there  occurs  rather  frequently,  either  during  the  attack  or 
before  it,  drawing  of  the  head  towards  one  shoulder.' 

Muscular  contractions  in  this   neighbourhood   are  probably 


NEUROSES  OF  THE  LARYNX. 


529 


accounted  for  by  reflex  stimulation  of  the  spinal  accessory  nerve ; 
and  the  symptom  of  this  character  which  was  exhibited  in  my 
second  case  is  allied  to  the  *  tonic  spasm  in  the  region  of  the 
sterno-cleido-mastoid  muscle,'  to  which  ^^E.  Fraenkel  has  alluded 
as  a  disagreeable  sequel  of  galvano-caustic  appHcations  to  the 
naso-pharynx. 

I  have  said  that  Brown-Sequard  does  not  specially  allude  to 
laryngeal  epilepsy,  but  his  table  of  causes  and  effects  of  the 
general  malady,  which  was  prepared  so  long  ago  as  1857, 
indicates  in  particulars  his  recognition  of  a  laryngeal  aura,  or  at 
least  of  the  presence  and  importance  of  tonic  contraction  of  the 
laryngeal  respiratory  muscles ;  and  his  observation  in  this  par- 
ticular is  generally  recognised. 

McBride,  amplifying  Krishaber's  definition  of  the  malady,  calls 
it  '  complete  spasm  of  the  glottis  in  adults ;'  but  unfortunately 
Krishaber's  case  is  the  only  doubtful  one  of  true  laryngeal  vertigo 
or  epilepsy  of  the  whole  fourteen  on  which  McBride  bases  his 
conclusion.  The  fact  that  there  is  always  a  complete  spasm  of 
the  glottis  does  not,  in  my  judgment,  warrant  us  in  ignoring  that 
the  reflex  effect  thereof  is  to  induce  a  nerve-storm,  or,  in  other 
words,  adopting  the  Brown-Sequard  definition  of  epilepsy,  *  an 
apyretic  nervous  affection  characterized  by  seizures  and  loss  of 
consciousness,  with  tonic  or  clonic  convulsions.' 

The  connection  of  epilepsy  is  still  more  strongly  marked  in  the 
case  of  reflex  nasal  neuroses,  as  will  be  seen  by  reference  to  the 
cases  observed  by  others  besides  myself,  which  are  reported  in 
the  next  chapter  (p.  545). 

And  this  brings  me  to  say  that  whatever  name  we  may  give  to 
this  affection,  there  will  probably  be  general  unanimity  as  to 
McBride's  explanation  of  the  mode  in  which  it  is  brought  about, 
namely,  by  cough ;  in  other  words,  by  a  series  of  spasmodic 
inspirations,  followed  by  spasmodic  expiration,  with  more  or  less 
complete  closure  of  the  glottis.  This  spasm  results  in  increased 
atmospheric  pressure  on  the  walls  of  the  pulmonary  alveoli,  which 
in  all  probability  prevent,  or  tend  to  prevent,  the  free  passage  of 
blood  through  the  lungs,  and  therefore  lessen  the  blood  in  the  left 
side  of  the  heart ;  the  pressure  on  the  large  intra-thoracic  veins 
hinders  the  return  of  venous  blood,  and  thus  we  understand  that 
the  face  will  be  pale  or  turgid,  according  as  the  spasm  of  the 
glottis  lasts  for  a  longer  or  shorter  time.  This  theory  is  supported 
by  the  addition  of  interesting  facts  from  Weber  on  the  effects  of 
forced  expiration  with  a  closed  glottis,  and  by  sphygmographic 
tracing  in  the  same  circumstances. 

Whilst  agreeing  with  the  view  that  alteration  in  intra-thoracic 
blood-pressure  from  glottic  spasm  is  the  prime  factor  in  the  in- 

34 


530 


DISEASES  OF  THE  THROAT  AND  NOSE. 


duction  of  the  nervous  phenomena,  I  am  strongly  of  opinion  that 
this  vascular  disturbance  almost  invariably  exerts  a  marked  effect 
on  the  cerebral  circulation,  which  finds  expression,  sometimes  in 
epileptiform  manifestations,  sometimes  in  simple  syncope  ;  nor 
does  their  peripheral  reflex  origin  militate  against  this  view  of 
their  central  connection.  A  quite  recent  paper  by  "^Brown- 
Sequard,  only  published  as  these  pages  are  passing  through  the 
press,  confirms  this  view,  the  author  holding  that  peripheral 
irritation  in  the  region  of  the  neck  is  capable  of  producing  in- 
hibition of  cardiac,  respiratory,  and  cerebral  activity. 

Prognosis  as  gathered  from  recorded  cases  is  favourable,  since 
the  disease  is  amenable  to  properly  directed  remedial  measures ; 
but  the  symptoms  are  decidedly  alarming,  and  the  possibility  that 
fatal  cases  of  this  character  may  have  been  registered  under  the 
heading  of  a  cardiac  failure  or  a  cerebral  lesion  must  not  be  over- 
looked. 

Treatment. — In  almost  every  case  that  has  derived  benefit, 
attention  has  rightly  been  directed  to  the  pharynx  rather  than  the 
larynx.  As  to  general  measures,  though  bromides  have  allayed 
and  doubtless  will  continue  to  allay  symptoms,  I  should  prefer 
iron  and  digitalis,  or  iron  and  ergot,  with  saline  purgatives, 
moderate  diet,  and  the  avoidance  of  alcohol  and  tobacco. 

Local  treatment  must  be  directed  to  relief  of  the  particular 
local  cause  of  the  disorder,  full  directions  for  which  will  be  found 
in  the  foregoing  pages  under  the  headings  of  '  Pharyngitis '  (p.  198) , 
*  Relaxed  Uvula  '  (p.  234),  or  '  Chronic  Laryngitis  '  (p.  295).  They 
have  also  been  indicated  in  the  history  of  the  treatment  of  my 
cases,  and  it  is  hardly  necessary  to  repeat  that  I  have  found 
especially  beneficial  results  from  destruction  of  enlarged  veins 
and  hyperaemic  hypertrophies  by  means  of  the  galvano-cautery. 


REFERENCES  TO  AUTHORITIES. 


PAGE. 


NO. 


NAME. 


TITLE  OF  WORK  REFERRED  TO. 


500 
504 
SI3 


2 


McBride. 
Von  Ziemssen. 


Med.  Journ.  July,  1885, 
Cyclopcsdia  of  Medicine^  vol.  vii. 
Op.  cit.,  p.  186. 


3 
4 
5 

6 

7 

8 

9 


gottstein, 
Lefferts. 


Irans.Intei-.Mcd.  Cong.,yo\.m.,  p.2 1 5.  1S81. 
Op.  cit.,  p.  419. 


Morell-Mackenzie. 
Whitfield  Ward. 


Arch,  of  LaryugoL,  vol.  iii. ,  p.  142.  18S3. 

Berlin  Klin.  Vl'ochenschrift,  No.  23.   1 87 7. 

Virchow's  y?;r//z'z',  vol.  xxxiii.,  pp.  68,  269. 

Paral,  Matrices  du  Larynx.  Paris,  1869. 
/ Arch,  of  LaryngoL,  vol.  ii.,  p.  197,  18S1  ; 
\  and  Berlin  Klin.  IVochensch.,  No.  46, 1 883. 

Brit.  Med.  Journal,  Aug.,  1886. 


Baumler. 
Gerhardt. 

DURANTY. 


0 


Semon. 


1 1 


Semon  and  Horsley. 


12 


RoSENBACH. 


NEUROSES  OF  THE  LARYNX. 
REFERENCES  TO  AUTHORITIES— Con/ hmed. 


PAGE. 

NO. 

NAME. 

13 

Hooper. 

14 

F.  Donaldson,  jun. 

514 

15 

Krause. 

C  I  A 

!)  '4 

16 

Cohen. 

514 

17 

Mandlkstamm. 

18 

Exner. 

19 

Weinzweig. 

516 

20 

QUAIN. 

21 

Kopp. 

22 

Mantle. 

23 

Morell-Mackenzie 

24 

Lefferts. 

523 

25 

Charcot. 

26 

523 

27 

Gasquet. 

523 

28 

IvRIbHABER. 

523 

29 

G  RAY. 

523 

30 

McBride. 

523 

31 

Russell. 

523 

32 

Massei. 

523 

33 

Knight. 

'  523 

34 

Sommerbrodt. 

528 

35 

Brown-Sequard. 

529 

36 

E.  Fraenkel. 

529 

37 

Weber. 

530 

38 

Brown-Sequard, 

title  of  work  referred  to. 


7 Ne7(/  York  MecC.  Jciirnal,  July  4,  1885  ; 

and  Ibid.^  June  5,  1886. 
{ Ainer.  Journal  of  Med.  Sciences^  July> 
1  1885. 

Rev.  Mens.de  I.aryngol.,  Nov.,  1886. 

^ Inter nat.  Encyclopced.    Surgery,  p.  783. 

\    New  York,  1884. 

{Monalschft.fiir  Ohrenheilhtnde,  etc.,  Dec, 
1884. 

Centralblatt fiir  Lajyngologie,  Feb.,  1885. 
/ Monatschft.fiir  Ohreiiheillninde,  etc.,  Dec  , 
\  1884. 

f  Dictionary  of  Medicine,  p.  193.  London, 
\  1883. 

f  Denkiviirdigkeiten-    in    der  Aertzlichen 
\     Praxis.    Frankfort,  1830. 
\Brit.  Med.  Journ.,  Feb.  8,  1890,  p.  286. 

Ojy.  cit.,  p.  490. 

^Archives  of  Latytigology,  vol.  iii.,  p.  165. 
\    New  York,  1883. 

^  Comptes  rendtis  de  la  Societe  de  Biologic, 
\    p.  336.    Paris,  1876. 

Le  Progres  Medical,  xvii.,  p.  317.  1879. 

Practitioner,  August,  1878. 
(Ann.  des  Mai.  de  F Oreille  et  du  Larynx, 
\     p.  1 82.  1882. 

( Ainer.  Jonrn.  of  Neurology   and  Psy- 
\\    chiatry,  Nov.,  1882. 
\{Edin.  Med.  Journal,  March,  18S4  ;  and 
-!     Appendix  to  Plnglish   Translation  of 

\  Gott stein,  p.  260,  1886. 

Birviinghani  Med.  Pev.,  Augusi,  1884. 

^  Giorn.  Internal,  delle  Scicnxe  Medicate, 

\    anno  vi. 

New  York  Med.  Journal,  July  10,  1886. 

Berlin  Klin.  Wochenschrift,  Sept.  25,  1876. 
/Quain's  Dictionary  of  Medicine,  p.  444. 
\    London,  1883. 

{Trans.  Internat.  Med.  Congress,  vol.  iii., 
p.  301.  1881. 
Miiller's  Archives,  1 85 1. 
Acadanie  des  Sciences,  April  4,  1887. 


CHAPTER  XXIV. 


THE  GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  NASAL  AND 
NASO  PHARYNGEAL  DISEASES. 

In  a  previous  portion  of  this  book  (Chapter  I.,  p.  33  et  seq,),  I 
have  described  the  crude  anatomy  and  physiology  of  the  nasal 
passages,  have  given  (Chapter  V.,  p.  76  et  seq.)  directions  for 
their  examination,  and  have  repeatedly  insisted  on  the  import- 
ance of  recognition  and  treatment  of  diseased  states  in  these 
regions  in  relation  to  a  more  complete  diagnosis  and  reHef  of 
throat  conditions  than  is  otherwise  attainable. 

It  is  not,  however,  possible  within  the  hmits  prescribed  to  me, 
to  treat  of  diseases  of  the  nasal  fossae  with  the  same  detail  as  has 
been  afforded  to  those  of  the  pharynx  and  larynx ;  nor,  indeed,  is 
it  altogether  necessary,  for  although  the  subject  is  of  the  highest 
importance,  and,  moreover,  of  almost  fascinating  interest,  and 
capable  of  application  and  elucidation  in  many  varied  aspects,  the 
actual  morbid  conditions  may  be  generalized  under  a  compre- 
hensive classification  of  quite  moderate  limits. 

I  propose,  therefore,  to  review,  as  it  were,  our  present  know- 
ledge of  the  subject  from  a  general  standpoint,  and  then  as 
concisely  as  possible  to  indicate  the  principal  symptoms,  functional 
and  physical,  as  well  as  the  lines  for  treatment,  of  the  more  usual 
nasal  diseases  to  be  met  with  in  practice. 

THE  NASAL  MUCOUS  MEMBRANE. 
The  nasal  chambers  are  not  only  the  seat  of  the  sentient  surface 
connected  with  the  sense  of  olfaction,  but  they  are  the  natural 
avenues  through  which  the  air  reaches  the  organs  of  respiration, 
audition,  and  voice-production.  When  the  nasal  membrane  is 
diseased,  neighbouring  portions  of  the  respiratory  tract  are,  as  a 
consequence,  more  or  less  profoundly  affected :  (i)  By  direct 
extension  of  the  morbid  process  to  contiguous  areas  ;  (2)  by 
abeyance  of  the  function  of  warming,  moistening,  and  filtering 
inspired  air,  in  consequence  of  which  the  latter  enters  cold,  dry, 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  533 


and  loaded  with  foreign  particles,  thus  conducing  to  disease  of  the 
pharynx,  larynx,  lower  passages,  and  even  lungs  ;  and  (3)  by 
reflex  induction  of  certain  neuroses  in  adjacent  correlated  tracts. 
Under  this  last  heading  are  included  nasal  cough,  many  forms  of 
asthma,  hay  fever,  nasal  vertigo  and  allied  conditions. 

In  order  to  thoroughly  appreciate  morbid  conditions  of  the 
mucous  lining,  we  must  consider  its  structure  somewhat  more 
minutely  than  has  been  done  in  the  anatomical  description  of  our 
first  chapter. 

We  have  already  seen  that  the  nasal  membrane  is  continuous 
with  that  of  the  pharynx,  and  extends  into  the  antrum  of  Highmore, 
and  other  accessory  cavities,  as  well  as  into  the  Eustachian  tube. 
The  superficial  portion  of  the  membrane  may  be  roughly  divided, 
according  to  its  microscopic  character  and  physiological  functions, 
into  two  portions :  a  superior  or  olfactory,  and  an  inferior  or  respi- 
ratory tract. 

Olfactory  Region. — This  portion  of  the  nasal  cavity  includes 
the  upper  half  of  the  septum,  the  superior  turbinated  bone,  and  the 
upper  half  of  the  middle  one ;  the  membrane  in  this  situation  is 
more  closely  adherent  to  the  periosteum,  and  relatively  thinner 
than  in  the  respiratory  area.  The  following  points  merit  especial 
attention,  viz. : 

I.  That  the  olfactory  portion  is  not  very  vascular. 

II.  That  it  is  only  moderately  supplied  with  glands,  which  are 
of  the  variety  known  as  serous. 

III.  That  it  is  of  a  rather  pale  sepia  colour,  due  to  the  presence 
of  a  pigment  in  the  epithelial  cells. 

IV.  That  the  substance  of  the  membrane  consists  mainly  of 
non-meduUated  nerve-fibres — the  terminal  branches  of  the  olfac- 
tory nerves  which,  after  passing  through  the  fifteen  to  twenty 
apertures  of  the  cribriform  plate  of  the  ethmoid,  are  distributed 
solely  to  the  olfactory  region  ;  the  tract  is  also  supphed  with 
nerves  of  common  sensation. 

The  superficial  lining  of  this  area  of  special  sense  consists  cf 
a  stratified  and  tesselated  columnar  epithelium,  whose  free  surface 
is  destitute  of  ciha.  Between  these  columnar  cells  are  situated  the 
olfactorial  cells  of  Schultze,  delicate  spindles,  each  with  a  spherical 
nucleus.  The  cell  substance  surrounds  the  nucleus  as  a  thin  zone, 
and  sends  one  prolongation  towards  the  free  surface,  and  another 
more  deeply  to  join  a  delicate  nerve-plexus,  the  ultimate  rami- 
fications of  the  olfactory  nerves.  If  these  olfactorial  cells  are 
destroyed,  the  sense  of  smell  is  lost  just  as  completely  as  if  ih\i 
olfactory  lobes  or  nerves  had  been  sectioned. 


534 


DISEASES  OF  THE  THROAT  AND  NOSE. 


There  are  so  many  points  of  importance  concerning  the  respi- 
ratory functions  of  the  nose,  that  it  is  quite  impossible  to  discuss 
at  length  the  many  interesting  and  obscure  phenomena  connected 
with  olfaction.  Suffice  it  to  say  that  the  sense  of  smell  is  depen- 
dent on  a  healthy  condition  of  the  olfactory  and  trigeminal  nerves, 
on  the  due  nutrition  and  moisture  of  the  mucous  membrane,  and 
on  the  presentation  of  the  odoriferous  material  to  the  olfactory 
region  in  a  state  of  vapour  or  perhaps  of  very  fine  powder. 
Beyond  this  little  is  positively  known  as  to  the  exact  manner  in 
which  an  odorous  substance  at  a  distance  is  able  to  produce  the 
sensation  and  perception  of  smell.  ^Graham  started  the  hypo- 
thesis that  olfaction  consists  essentially  in  an  oxygenation  of  the 
odorous  material  within  the  nostril,  and  in  the  stimulant  effect  of 
that  chemical  process  upon  the  sentient  nerves  of  the  olfactory 
region.  This  theory  certainly  harmonizes  with  the  fact  that 
odorous  substances  in  general,  such  as  ethers,  aldehydes,  and 
essential  oils,  belong  to  the  organic  kingdom,  and  can  be  readily 
acted  on  by  oxygen.  Chemical  action  no  doubt  affects  the  nasal 
membrane,  as  in  those  cases  in  which  inhalation  of  gases  such  as 
ammonia  and  sulphurous  acid  causes  a  sense  of  pungency ;  but 
this  is  not  the  kind  of  chemical  action  understood  by  Graham, 
for  it  is  probable  that  pungency  is  due  to  stimulation  of,  not 
chemical  action  on,  the  terminal  branches  of  the  nerves  of 
common  sensation  (iifth  pair). 

A  view  opposed  to  that  of  Graham  is  the  vibratory  theory, 
originally  suggested  by  ^Dr.  William  Ogle,  according  to  which 
odorous  impressions  are  considered  to  be  the  result  of  vibrations. 
Basing  his  view  on  the  fact  that  pigment  is  present  in  the  olfactory 
region  and  essential  to  perfect  olfaction,  much  in  the  same  way 
that  luminous  vibrations  are  absorbed  by  the  choroidal  pigment, 
Ogle,  in  an  article  on  '  Anosmia,'  brought  together  a  number  of 
facts  to  show  that  albino  animals  are  deficient  in  pigment  and 
in  the  sense  of  smell ;  as  a  consequence  they  die  early,  being 
handicapped  in  the  struggle  for  existence  by  their  inabilit}-  to 
protect  themselves  against  poisonous  plants,  dangerous  inhalations 
and  insanitary  habitations. 

The  part  played  by  the  olfactory  region  in  the  perception  of 
flavours  is  well  known :  savoury  meats  and  wines  are  really  smelt, 
a  fact  which  can  be  proved  by  plugging  the  anterior  and  posterior 
nares,  and  it  is  further  confirmed  by  the  constant  association 
of  want  of  perception  of  flavours  with  loss  of  smell. 

Anosmia  may  be  occasioned  by  several  classes  of  lesions  :  first, 
by  mechanical  impediments  to  the  admission  of  odorous  molecules 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DLSEASES.  535 


to  the  sentient  surfaces — amongst  these  causes  may  be  named 
polypi,  rhinal  calculi,  congenital  or  cicatricial  malformations  of  the 
nostrils,  deviations  of  the  septum,  acute  and  chronic  thickening  and 
swelling  of  the  membrane,  all  leading  to  stenosis.  Secondly,  the 
function  is  impaired  by  all  nutritive  or  destructive  changes  of  the 
membrane,  which  lead  to  degeneration  of  the  glands  and  nerve 
filaments.  Under  this  heading  come  such  destructive  lesions  as 
atrophic  rhinitis,  strumous,  syphilitic,  and  other  forms  of  caries  and 
necrosis ;  disordered  nutrition  and  loss  of  function  are  also  oc- 
casionally directly  associated  with  paralysis  or  paresis  of  the 
trigeminal  nerves.  And  thirdly,  anosmia  may  result  from  various 
lesions  causing  destruction  or  impaired  functions  of  the  olfactory 
nerves  in  their  continuity,  as  by  fractures  and  new  growths,  or 
centrally  by  disease  of  the  olfactory  lobes,  or  other  intracranial 
mischief.  In  all  of  these  instances  the  lesion  may  be  unilateral. 
It  remains  to  be  added  that  the  cause  may  occasionally  be  much 
less  directly  nasal. 

I  was  consulted,  in  April,  1879,  by  a  lady  on  account  of  loss  of  smell,  for  which  I 
could  fiiid  no  reason  beyond  a  chronic  pharyngitis  and  a  very  relaxed  uvula.  For  the 
relief  of  the  pharyngeal  trouble  I  reduced  the  lengthened  uvula  by  abscission,  with  the 
somewhat  unexpected  result  that  the  anosmia  was  entirely  cured.  Since  that  time  I  have 
seen  other  instances  which  have  assured  me  that  this  experience  was  not  unique. 

I  have  already  alluded  to  the  intimate  connection  of  the  fifth 
pair  of  nerves  with  the  sense  of  olfaction.  These  nerves  doubtless 
preside  over  several  separate  functions,  and  contain  distinct  kinds 
of  fibres  for  their  due  performance.  Thus  one  set  regulates  the 
working  of  the  local  vaso-motor  mechanisms  and  the  blood-supply 
of  the  mucous  membrane ;  another  controls  the  amount  and 
character  of  the  glandular  secretion  ;  yet  another  set — the  trophic 
fibres — will  preside  over  the  nutrition  of  the  part ;  whilst  a  fourth 
will  respond  to  the  stimuli  of  common  sensation,  and  warn  the 
lungs  of  the  approach  of  irritating  bodies  and  gases. 

It  is  not  surprising,  therefore,  that  olfaction  should  be  im- 
paired by  anything  which  interferes  with  the  due  performance  of 
these  varied  functions  of  the  fifth  nerve ;  and  this  is  amply  borne 
out  by  clinical  experience,  as  will  be  seen  when  we  come  to  con- 
sider the  symptoms  of  various  nasal  diseases. 

Respiratory  Region. — The  membranous  lining  of  the  lower  or 
respiratory  area  is  pink  in  colour,  and  consists  superficially  of  two 
layers  of  columnar  cells  with  conical  ends  ;  the  bases  of  the  cells 
of  the  outer  layer  look  towards  the  lumen  of  the  fossse,  and 
are  amply  ciliated.  In  this  respect,  the  epithelial  lining  differs 
markedly  from  that  of  the  olfactory  region,  where,  as  we  have 


536 


DISEASES  OF  THE  THROAT  AND  NOSE. 


seen,  the  columnar  cells  bear  no  cilia,  and  the  smootkness  of  the 
membrane  is  only  interrupted  by  the  little  projecting  ends  of 
Schultze's  cells.    Beneath  the  epithelium  is  found  the  usual  base- 
ment membrane,  a  structure  presenting  little  differentiation,  but 
perforated  for  the  transmission  of  the  terminal  branches  of  the 
fifth  pair  of  nerves  and  for  the  gland-ducts..    Underneath  this 
apparently  unimportant  structure  is  found  a  mass  of  adenoid 
tissue,  more  or  less  diffuse,  but  here  and  there  aggregated  as 
lymph-follicles.    These  collections  of  lymphoid  tissue  form  a 
potential  nasal  tonsil,  whose  function  is  doubtless  to  secrete  serum, 
and  leucocytes,  for  scavenging  purposes,  into  the  rhinal  passages. 
In  the  deeper  portion  of  this,  which  is  often  known  as  the  mucous 
layer,  are  found  a  large  number  of  glands,  the  alveoli  and  ducts  of 
which  are  grouped  together  in  corresponding  lobules.  These 
glands  are  of  two  kinds,  the  mucous  and  serous.    The  latter, 
which  are  identical  with  the  true  salivary  glands  in  structure,  are 
much  larger  and  far  more  numerous  than  the  former.    There  is, 
however,  one  feature  about  these  glands  which  is  of  both  physio- 
logical and  pathological  interest  :  viz.,  that  in  the  thicker  areas  of 
the  mucous  membrane,  the  alveoli,  especially  those  near  the 
surface,  are  filled  by  large  and  small  globules  of  fatty  matter 
resembling  that  found  in  sebaceous  and  Meibomian  glands.  In 
ozsena  the  crusts  and  discharges  usually  contain  decomposing 
fatty  globules,  and  micro-organisms ;  hence  the  offensive  odour. 

^Klein  describes  fine  bundles  of  muscular  fibres  as  occurring  in 
the  inter-alveolar  tissue  of  Guinea-pigs  and  rabbits,  and  considers 
that  their  function  is  to  aid  in  the  discharge  of  the  gland-contents  ; 
he,  however,  makes  no  allusion  to  similar  structures  in  man.  In 
this  matter  modern  works  on  physiology  are  somewhat  behind  the 
times,  for  mention  is  not  made  of  what  anyone  will  readily 
make  out  who  takes  the  trouble  to  remove  and  examine  micro- 
scopically a  portion  of  the  membrane  covering  the  inferior  tur- 
binated bone,  namely,  an  erectile  tissue  of  venous  sinuses  and 
fibro-muscular  trabeculse,  homologous  with  the  corpora  cavernosa 
of  the  penis.  This  layer  of  erectile  tissue  is  limited  principally  to 
the  respiratory  portion  of  the  nose — that  is,  to  the  lower  and  pos- 
terior parts  of  the  inferior  turbinated  bodies  ;  but  it  is  also  to  be 
found  in  the  deepest  layers  of  the  mucosa  covering  the  superior 
and  middle  turbinal  bones  ;  it  is,  however,  on  the  inferior  turbinal 
that  it  attains  its  greatest  development.  The  veins  from  these 
sinuses  pass  in  five  different  directions,  viz.,  to  the  plexuses  of  the 
face,  cranium,  orbit,  soft  and  hard  palate. 

'^John  N.  Mackenzie  has  recently  shown  that  so  long  ago  as 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  537 


1769  ^Morgagni  drew  attention  to  the  peculiar  and  '  red  thick- 
nesses of  the  membrane  of  the  nose from  his  description  he 
appears  narrowly  to  have  missed  the  discovery  of  the  turbinated 
erectile  tissue.  ^Toynbee,  in  his  '  Diseases  of  the  Ear,'  says  : 
*  Many  years  ago  I  pointed  out  the  peculiar  erectile  tissue  of  the 
nasal  mucous  membrane,  not  only  in  man,  but  in  other  mammalia  ; 
this  tissue  is  a  most  efficient  respirator.'  In  1853,  "Kohlrausch 
injected  the  tissue  from  the  jugular  vein,  and  looked  on  it  as  a 
^  cavern  oils  network  of  veins  just  underneath  the  mucous  layer.' 
Such  a  plexus  had  been  previously  referred  to  by  ^Hyrtl,  and  was 
subsequently  claimed  as  an  independent  discovery  by  ^Kolliker. 
Kohlrausch  evidently  mistook  the  erectile  spaces  for  venous 
trunks,  and  failed  to  appreciate  the  true  contractile  or  erectile 
character  of  the  tissue,  which  was  subsequently  set  forth  by 
^^Bigelow  in  1875.  This  last-named  observer,  in  an  article  familiar 
to  all  specialists,  described  the  tissue  with  great  accuracy,  and 
defined  its  limits.  Bigelow  was  the  first  to  observe  the  alternate 
distension  and  collapse  of  the  erectile  bodies,  thereby  leading  the 
way  to  the  rational  interpretation  of  nasal  affections.  From  their 
resemblance  to  the  cavernous  structures  of  the  penis  he  gave 
them  the  name  of  the  turbinated  corpora  cavernosa;  ^^Zucker- 
kandl  has  pointed  out,  they  may  with  more  propriety  be  classed 
amongst  the  erectile  tissues.  At  the  International  Medical 
Congress  in  1881,  ^^Bosworth  described  the  tortuous  condition  of 
the  arteries  of  the  turbinated  bodies,  the  so-called  helicine  arteries  ; 
and  he  also  drew  attention  to  the  fact  that  in  hypertrophy  of  the 
turbinated  mucous  membrane  there  is  overgrowth  of  the  surface 
layer,  of  the  adenoid  layer,  of  the  racemose  glands,  and  of  the 
connective  tissue  between  the  enlarged  vascular  sinuses. 

In  a  more  recent  contribution  ^^Bosworth  has  denied  the 
erectile  nature  of  '  the  true  erectile  tissue  '  of  Bigelow,  to  which 
he  formerly  subscribed.  He  believes  that  nasal  serosity  is  largely 
due  to  exosmosis  direct  from  the  vascular  tissue,  and  not  to 
glandular  mechanism.  Such  exosmosis  from  the  small  capillaries 
may  occur,  but  it  must  be  an  insignificant  factor  in  the  production 
of  the  rhinal  fluids.  Undoubtedly,  however,  the  lymphoid  tissues 
contribute  to  the  secretion,  which  is  usually  beheved  to  be  the 
exclusive  result  of  the  activity  of  the  mijcous  and  serous  glandular 
mechanisms.  i^Bosworth  makes  the  extraordinary  statement  that 
in  the  nasal  mucosa  '  there  are  no  serous  glands,'  whereas,  as  has 
been  remarked  above,  the  serous  glands  are  both  larger  and  more 
numerous  than  the  mucous. 

No  good  purpose  would  be  served  by  a  recapitulation  of  the 


538 


DISEASES  OF  THE  THROAT  AND  NOSE. 


sizes  and  shapes  of  cells  and  other  details  which  have  no  very 
important  bearing  on  etiological  and  pathological  considerations; 
but  it  is  necessary  to  dwell,  albeit  briefly,  on  the  normal 
physiological  functions  of  the  respiratory  region. 

The  nostrils,  in  the  first  place,  offer  a  double  aperture  for  the 
admission  of  air  ;  floating  dust  and  coarse  particles  are  caught  by 
the  vibrissse  or  hairs  which  keep  sentinel  at  the  entrance ;  the 
moist  and  ciliated  mucous  lining  is  eminently  adapted  by  its 
irregular  contour  and  its  vibratile  cilia  to  catch  any  finer  particles 
which  on  being  deposited  act  as  stimuli  to  the  glands ;  as  a 
result,  a  secretion  is  poured  out  which  veritably  sluices  the 
nostril.  The  cilia,  however,  work  in  the  direction  of  the  naso- 
pharynx ;  it  is  therefore  probable  that  in  health  the  secretion  of 
the  nasal  glands  is  carried  to  the  throat,  and  there  either  re- 
absorbed or  swallowed  ;  when  the  balance  between  secretion  and 
its  physiological  removal  by  backward  ciliary  action  is  interfered 
with,  as  in  acute  catarrh,  a  running  from  the  nose  results.  It  will 
be  seen,  therefore,  that  the  cilia  in  the  respiratory  tracts  of  the 
nose  have  a  very  definite  and  important  function  to  perform,  viz., 
the  removal  of  mucus  and  of  foreign  bodies  deposited  on  the 
surface  from  the  inspired  air.  If  these  cilia  are  destroyed  this 
function  ceases,  and  as  a  consequence  a  chronic  inflammation 
results,  with  all  its  train  of  evils  in  the  way  of  hypertrophies  and 
hyper-secretions ;  atrophy,  with  arrested  or  perverted  secretion ; 
polypi,  etc.  It  is  my  conviction  that  destruction  of  the  cilia  is 
often  the  first  pathological  change  in  a  chronic  catarrh  ;  and  if  so, 
one  readily  recognises  the  evils  of  snuff-taking  and  tobacco,  of 
alcoholic  fumes,  and  also  of  medicated  inhalations  of  a  pungent  or 
irritant  character. 

In  all  probability,  however,  by  far  the  most  important  function 
of  the  nostril  is,  not  to  simply  filter  the  air  from  dust,  but  to 
warm  and  moisten  it.  ^^Morell  Mackenzie  alludes  to  some  ex- 
periments which  tend  to  prove  this  point ;  and  more  recently 
^^Aschenbrandt  has,  in  the  physiological  laboratory  of  Professor 
Fick,  at  Wiirzburg,  conducted  some  more  accurate  investigations 
in  the  same  direction.  His  method  was  to  estimate  the  difference 
between  the  temperature  and  moisture  of  air  passed  by  a  glass 
tube  through  the  mouth  to  the  posterior  nares,  thence  through 
the  nasal  fossae  to  the  anterior  nares.  These  experiments  con- 
clusively prove  that  almost  the  whole  of  the  brunt  of  moistening 
and  warming  the  inspired  air  is  borne  b}*  the  nose  during  normal 
breathing.  There  can  be  no  doubt  that  the  complexity  and 
freedom  of  the  vascular  and  glandular  supply  of  the  nasal  fossce 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  539 


in  health  are  well  adapted  for  the  thorough  carrying  out  of  this 
function.  Even  in  mouth-breathers  and  in  those  obliged  to 
respire  through  a  tracheotomy-tube,  the  exspired  air  is  always 
hotter  and  moister  than  the  inspired,  and  it  stands  to  reason  that 
the  lungs  must  in  such  cases  lose  heat — (i)  by  conduction,  whenever 
the  temperature  of  inspired  air  is  less  than  blood-heat ;  and  (2) 
by  loss  of  heat  brought  about  by  evaporation  of  water  from  the 
lungs,  on  account  of  the  low  vapour  tension,  due  to  the  fact  that 
the  air  has  not  been  moistened  in  the  nose.  This  state  of  affairs, 
which  exists  whenever  there  is  blocking  of  the  nostrils  or  of 
the  naso-pharynx,  necessarily  acts  prejudicially  on  the  lower  air- 
passages  in  particular,  as  well  as  on  the  organism  at  large. 

^^Bloch's  important  and  valuable  physiological  investigations  on 
nasal  respiration  led  him  to  formulate,  amongst  others,  the  follow- 
ing conclusions  : 

1.  The  temperature  of  the  inspired  air  is  considerably  raised 

while  passing  through  the  nasal  cavities,  the  expired  air 
being  1*5°  to  2°  C.  higher  after  nasal  respiration. 

2.  The  thermogenic  action  of  the  nasal  mucosa  is  greater  when 

the  temperature  of  the  external  air  is  lower ;  this  thermo- 
genic effect  is  constant,  and  depending  on  the  relations  of 
the  external  temperature  and  the  temperature  of  the  body, 
can  be  expressed,  under  normal  conditions,  by  the  formula 

E  =  K37-t).  ^ 

3.  The  thermogenic  action  of  the  buccal  cavity  is  slight,  com- 

pared with  that  of  the  nasal. 

4.  The  heat  given  up  by  the  mucosa  of  the  nose  (and  its 

diverticula)  at  each  inspiration,  and  at  a  moderate  ex- 
ternal temperature,  is  equivalent  to  6  gramme-calorics. 

5.  Inspired  air  passes  out  of  the  nose  about  f  saturated. 

(Keyser  and  Aschenbrandt,  however,  maintain  that  it  passes 
out  fully  saturated  with  moisture). 

6.  The  nose,  though  not  a  perfect  filter  of  dust,  retains  the 

greater  part  of  the  solid  particles  inspired ;  the  amount 
filtered  depending  on  the  viscidity  of  the  mucosa,  and  the 
weight,  size,  and  hygroscopic  properties  of  the  solid  matter 
inhaled. 

7.  During  normal  nasal  respiration  the   tongue   is  pressed 

against  the  palate  and  the  mouth  is  kept  closed,  both 
anteriorly  and  posteriorly,  solely  by  the  pressure  of  the 
external  air. 

8.  Every  comiderahle  mechanical,  chemical,  or  thermic  stimulus 

acting  upon  the  nasal  mucous  membrane  through  the 


540 


DISEASES  OF  THE  THROAT  AND  NOSE. 


inspiratory  air  current,  induces  an  immediate  cessation 
of  the  respiratory  act.  This  respiratory  standstill  is  imme- 
diately succeeded  by  an  inspiration.  It  is  probable  that 
weak  stimuli  retard  inspiration,  and  that  very  strong 
stimuli  induce  an  immediate  expiratory  effort. 
^^MacDonald's  observations  are  in  substantial  agreement  with 
the  more  comprehensive  ones  of  Bloch. 

The  function  of  the  Nose  in  Voice  Production  has  been  fre- 
quently alluded  to  in  this  work,  but  a  few  words  of  recapitulation 
will  here  be  useful.  Voice  is  due  to  the  vibrations  of  a  column  of 
air  passing  up  from  the  lungs,  through  the  larynx,  to  the  mouth 
and  nose ;  the  pitch  of  the  voice  is  regulated  by  the  tension  and 
approximation  of  the  vocal  cords,  the  volume  by  the  force  of  the 
pulmonary  blast  through  the  glottis,  while  tone  is  dependent  on  the 
shape  of  the  oral,  nasal  and  pharyngeal  cavities,  and  on  the 
movements  of  the  palate  and  pillars  of  the  fauces.  Articulate 
language  depends,  in  addition,  on  movements  of  the  palate, 
tongue,  cheeks,  and  lips.  In  uttering  the  vowel  sounds,  the  nasal 
cavity  is  shut  off  from  the  mouth  by  the  soft  palate,  whilst  the 
velum  is  relaxed  in  forming  such  letters  as  m  and  n,  which  are 
said  to  possess  a  nasal  twang.  Helmholtz  has  shown  that  the 
fundamental  note  originating  from  vibrations  of  the  vocal  cords 
gives  rise  to  a  series  of  secondary  vibrations  of  the  current  of  air 
in  the  nasal  cavities,  which  over-tones  serve  to  reinforce  the  har- 
monics of  the  voice  and  add  to  their  quality.  Phonation  and 
articulation  are  therefore  not  only  impaired  in  the  victims  of 
nasal  obstruction,  but  in  this  condition  singing  in  the  falsetto 
register  is  impossible. 

From  what  has  been  said  it  will  be  seen  that  in  the  discharge  of 
its  respiratory  function  the  nasal  passages  are  constantly  exposed 
to  ever-changing  atmospheric  conditions  of  heat  and  cold,  dryness 
and  moisture.  The  amount  of  its  blood-supply  and  glandular 
secretion  will,  therefore,  vary  with  every  barometric  fluctuation, 
with  every  breeze  that  blows,  and  with  every  vitiating  influence  of 
the  atmosphere.  In  order  that  the  membrane  may  from  time  to 
time  adapt  itself  to  these  constantly  variable  circumstances,  it  is 
evident  that  a  sensitive  and  regulating  nervous  mechanism  will  be 
required  to  correlate  and  control  the  activity  of  the  glandular  and 
vascular  supply.  Such  a  mechanism  evidently  does  exist  in  con- 
nection with  the  spheno-palatine  ganglion  and  the  fifth  pair  of 
nerves.  The  sensitiveness  of  this  area  is  beyond  all  question  ; 
for  the  nasal  lining  readily  responds  to  direct  stimuli,  whether 
mechanical,  chemical,  galvanic,  or  thermal  ;  the  immediate  effect 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  541 


is  usually  a  blanching  of  the  membrane,  to  be  followed,  according 
to  the  nature  and  duration  of  the  stimulus,  by  a  more  or  less  obvious 
congestion  and'swelling  of  the  erectile  structures  and  an  increased 
secretion. 

This  congestion  or  erection  of  the  vascular  portion  of  the 
membrane  generally,  and  of  the  turbinated  corpora  cavernosa  in 
particular,  with  accompanying  hyper-secretion,  is  the  condition 
temporarily  met  with  in  every  ordinary  catarrh,  and  permanently 
established  in  the  swollen  state  of  the  membrane  known  as 
rhinitis  hypertrophica.  ^'^Seiler,  ^^John  Mackenzie,  and  other 
Americans,  and  more  recently  Continental  workers,  have  shown 
that  the  fully  established  hypertrophic  condition  is  the  final 
result  of  constantly  recurring  abnormal  erections  of  the  turbinated 
corpora  cavernosa  and  other  vascular  sites  in  the  nose.  It  must 
not,  however,  be  assumed  that  the  stimuli  necessary  for  this 
erection  need  be  applied  directly  to  the  interior  of  the  nostril, 
for  a  number  of  experimental  and  clinical  data  clearly  show  that 
this  is  much  too  narrow  a  view.  Mechanical  irritation,  as  from 
particles  of  snuff,  the  pollen  of  grasses  and  other  flowers,  fine 
dust,  etc.,  is  almost  as  important  a  factor  in  the  production 
of  nasal  erection  as  changes  in  the  temperature  of  the  atmo- 
sphere; and  if  long  continued  will  certainly  lead  to  a  permanently 
enlarged,  swollen,  and  hypertrophied  condition  of  the  erectile 
tissue  and  mucous  membrane  generally ;  but  this  state  of  affairs 
can  be  brought  about  in  quite  a  different  manner  than  by  direct 
stimulation  of  the  membrane  producing  reflex  erection.  ^^Woakes, 
who  is  most  enthusiastic  on  this  question  of  correlated  action, 
has  drawn  attention  to  a  number  of  examples  of  peculiar  reflex 
functions  of  the  nervous  system  which  obtain  in  connection  with 
organs  supplied  by  the  upper  portion  of  the  sympathetic  system. 
To  take  a  simple  example  :  in  passing  a  Eustachian  catheter  one 
often  notices,  amongst  other  things,  excessive  lachrymation. 
In  this  case,  clearly  the  nasal  membrane  is  in  nervous  connection 
with  the  tear  gland  through  the  vaso-dilator  nerves  in  the  fifth. 
Conversely  a  flash  of  light  will  cause  sneezing.  Stimulation  of 
one  spot  produces  vaso-motor  dilatation  of  the  vessels  of  another. 
This  is  because  the  nervous  mechanisms  of  the  two  areas  are 
correlated  and  intimately  connected,  which  connection,  however, 
is  usually  only  rendered  evident  under  the  influence  of  some  ex- 
ceptional or  powerful  stimulus.  In  the  example  quoted  the  two 
correlated  areas  are  separated  by  only  a  few  inches  of  nervous 
tissue,  but  the  correlation  existing  between  the  breast  and  organs 
of  generation  shows  that  two  auite  distinct  structures  may  be 


542 


DISEASES  OF  THE  THROAT  AND  NOSE. 


affected  in  unison  if  only  the  nervous  connection  be  intact;  and 
this  fact  the  better  enables  one  to  appreciate  the  remarkable  essay 
by  John  Mackenzie,  to  which  allusion  has  already  been  made 
(P-  35))  '  Irritation  of  the  sexual  apparatus,  as  an  etiological 
factor  in  the  production  of  nasal  disease.'  This  author  calls 
attention  to  the  intimate  physiological  relationship  which  exists 
between  the  nasal  and  reproductive  apparatus,  which  is  partially 
explained  by  the  theory  of  reflex  or  correlated  action,  partially 
by  the  bond  of  union  which  exists  between  the  various  erectile 
structures  of  the  body.  He  draws  attention  to  the  fact  that  in  a 
certain  proportion  of  women  with  healthy  nasal  organs,  engorge- 
ment of  the  turbinated  corpora  cavernosa  occurs  regularly  at  each 
menstrual  flow.    This  is  physiological  sympathy. 

Clinically  there  are  some  facts  which  appear  to  lend  support  to 
this  view,  for  it  is  often  noted,  if  due  inquiries  be  made,  that 
nasal  affections  become  much  more  troublesome  at  the  menstrual 
epoch ;  the  symptoms  are  aggravated,  and  in  ozaena  the  dis- 
charge is  decidedly  more  foetid.  Of  this  fact  I  have  long  been 
cognizant  in  my  own  practice.  Again,  epistaxis  in  boys  and  girls 
at  puberty,  and  vicarious  nasal  menstruation,  are  quite  in  accord- 
ance with  the  same  hypothesis.  There  are  some  who  always 
suffer  from  coryza  after  a  venereal  debauch  ;  and  nasal  diseases 
are  constantly  aggravated  by  sexual  excesses.  It  is  probable  that 
the  same  fact  obtains  in  connection  with  masturbation.  Finally, 
it  is  quite  possible,  to  quote  John  Mackenzie,  '  that  congestion 
of  the  nasal  erectile  tissue  precedes,  or  is  the  excitant  of,  the 
olfactory  impression  that  forms  the  connecting  link  between  the 
sense  of  smell  and  erethism  of  the  reproductive  organs  exhibited 
in  the  lower  animals.'  That  a  relationship  exists,  by  virtue  of 
which  irritation  of  the  genital  organs  reacts  upon  the  circulation 
and  nutrition  of  the  nose,  is  therefore  rendered  highly  probable  by 
the  evidence  of  chnical  investigation. 

If  this  excitation  of  the  nasal  membrane  be  carried  beyond  its 
physiological  limits,  there  comes  a  time  sooner  or  later  when  that 
which  is  a  normal  process  becomes  a  pathological  one,  according 
to  a  well  known  law  of  the  economy.  It  is  in  this  way  that  various 
stimuli,  whether  applied  directly  within  the  nostrils  or  reflexly 
through  the  nervous  system,  bring  about  in  course  of  time  chronic 
congestion  and  disordered  nutrition  of  the  nasal  membrane, 
leading  to  general  swelling  and  proliferation  of  the  constituent 
elements  and  of  the  turbinated  bodies  ;  in  point  of  fact,  to  one  or 
more  of  the  conditions  known  as  hypertrophic  rhinitis. 

On  the  other  hand,  congestion  and  hypertrophy  may,  after  a 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  543 

longer  or  shorter  time  of  perverted  growth  and  secretion,  lead  to 
an  increase  of  the  connective-tissue  elements  of  the  membrane  ; 
these  iiltimately  contract  and  culminate  in  fibroid  shrinking  and 
in  atrophy  of  both  membrane  and  bone.  Chronic  atrophic  rhinitis 
is  thus  established,  the  ciliated  epithelium  is  lost,  the  now  viscid 
and  fatty  secretion  is  not  swept  away  by  the  ciliary  action, 
microbic  growth  and  decomposition  takes  place,  and  ozsena  is  the 
final  result.  But  it  is  not  always  true  that  rhinitis  hypertrophica 
gives  place  to  the  atrophic  state,  nor  conversely  is  it  a  fact  that 
atrophic  rhinitis  is  always  a  result  of  hypertrophy,  though  such  is 
generally  considered  to  be  the  more  usual  sequence  of  events. 
Occasionally  atrophy  is  the  chief  factor  from  the  commencement ; 
but  the  precise  mechanism  and  set  of  causes  which  tend  to  bring 
about  this  condition  without  previous  hypertrophy  has  till  recently 
been  ill  understood,  and  yet  requires  further  elucidation.  ^-Bos- 
worth's  suggestion  that  it  is  due  to  drying  and  retention  of  the 
mucus  on  the  surface,  since  it  does  not  explain  such  antecedents 
as  loss  of  cilia  and  altered  secretion,  is  inadequate.  It  is  a  ques- 
tion worthy  of  consideration  whether  in  some  cases  of  so-called 
atrophic  rhinitis  and  especially  those  in  which  there  is  abnormal 
smallness  of  turbinated  bone,  there  has  ever  really  been  a  proper 
development  in  the  first  instance,  and  whether  the  condition  does 
not  represent  a  consequent  inability  of  the  tissues  to  perform  their 
natural  functions.  These  remarks  apply  more  particularly  to  that 
form  of  the  disease  known  as  strumous  ozcena,  which,  commencing 
at  six  or  seven  years  of  age,  occasionally  manifests  improvement 
at  the  period  of  puberty,  or  in  the  female  sex  after  marriage. 

Hypertrophy  of  the  membrane,  instead  of  resulting  only  in 
general  thickening,  which  is  most  prominent  over  the  septum 
and  turbinated  bones,  may  show  further  evidences  of  disordered 
nutrition  and  growth  in  the  shape  of  defined  hyperplasice  and 
distinct  neoplasms. 

It  is  beyond  the  scope  of  this  chapter  to  go  into  the  whole 
question  of  the  etiology  and  pathological  histology  of  nasal  polypi; 
but  it  may  be  briefly  stated  that  they  are  exuberant  growths 
containing  in  a  greater  or  smaller  proportion  the  elements  of  the 
mucous  membrane  from  which  they  spring.  Chronic  inflamma- 
tion and  ab  extra  irritation  seem  the  most  potent  factors  in 
their  etiology.  The  situation  of  true  potypi  indicates  that 
they  often  originate  as  a  circumscribed  cedema  of  pendulous 
portions  of  the  mucous  membrane.  My  own  experience  tends 
toward  support  of  the  view  that  a  polypoid  diathesis  may  be  a 
factor  of  importance. 


544 


DISEASES  OF  THE  THROAT  AND  NOSE. 


I  have  seen  two  cases  in  which  nasal  polypi  were  associated  with  laryngeal  growths ; 
and  others  in  which  there  were  warty  growths  on  the  uvula  or  some  other  portion  of  the 
soft  palate.  I  have  also  been  told  hy  patients  with  nasal  polypi,  that  they  have  suffered 
from  similar  neoplasms  which  have  required  surgical  treatment  in  the  uterus  and  rectum. 
Lastly,  I  have  recently  removed  a  very  large  polypus  blocking  up  the  whole  of  the  right 
nostril  and  dropping  back  into  the  post-nasal  space,  so  that  it  could  be  seen  by  oral 
examination.  The  growth  had  probably  commenced  about  three  years  previously,  and  at 
about  the  same  period,  the  patient,  a  young  lady,  then  eighteen  years  of  age,  noticed 
several  little  pendulous  warts  forming  on  the  right  side  of  the  neck,  and  limited  to  that 
situation. 

And  allied  to  this  question  is  that  of  heredity  of  nasal  polypi,  and 
of  family  predisposition  to  nasal  hyperplasias.  Of  this  circum- 
stance I  can  recall  several  instances : 

I  have  operated  on  three  brothers  in  one  family  for  nasal  polypi  ;  have  lately  treated  a 
young  lady  for  nasal  polypus,  whose  mother  has  also  a  similar  growth — never  operated  on 
— which  is,  I  believe,  the  chief  cause  of  a  chronic  bronchitis  ;  and  still  more  recently  I 
have  removed  a  polypus  from  a  lady,  aged  51,  who  has  yet  a  closer  family  history  in  the 
same  direction.  Her  mother  was  the  subject  of  an  enormous  polypus  which  would 
protrude  from  the  nostril  and  could  be  pushed  back  into  the  throat.  It  was  never  removed, 
and  the  subject  of  it  died  suddenly  with  symptoms  of  suffocation.  The  mother  of  this  last- 
named  lady  had  also  polypus,  and  her  father's  brother  was  similarly  afflicted. 

We  have  seen  that  the  circulation  and  nutrition  of  the  nasal 
membrane  is  capable  of  being  affected  reflexly  by  stimulation  of 
some  other  such  distant  portion  of  the  body  as  of  the  generative 
organs,  and  conversely  we  should  expect  to  find  that  stimulation 
or  irritation  of  the  nasal  membrane  v^^ould  cause  reflex  effects 
elsewhere.  The  simple  experiment  of  passing  a  catheter  or  probe 
into  the  nose,  to  which  I  previously  alluded,  causing,  amongst  other 
things,  sneezing  and  lachrymation,  is  ample  proof  that  such  is  the 
case.  But  there  are  a  number,  and  a  continually  increasing 
number,  of  clinical  data  which  support  the  view  that  the  presence 
of  nasal  polypi,  nypertrophied  turbinated  tissues  and  foreign 
bodies  in  the  nose  are  intimately  connected,  if  not  the  actual 
cause  of  various  asthmatic  symptoms.  ^s^V.  H.  Daly,  -^Roe, 
25Hack,  -*^John  Mackenzie,  and  ^^myself,  have  all  reported  cases  of 
asthma,  hay-fever,  and  rose-fever,  which  were  cured  by  simply 
treating  the  diseased  nasal  membrane  ;  but  the  first  to  point  out 
the  fact  of  the  connection  was  ^^Voltolini. 

2^Predborski  has  recorded  a  case  of  a  young  Jewess  who  suffered 
from  aphonia,  accompanied  by  paroxysms  of  dyspnoea,  one  of 
which  was  so  alarming  that  tracheotomy  was  contemplated. 
The  nose  showed  redness  and  tumefaction  of  the  turbinated 
areas ;  touching  them  produced  pain,  sneezing,  and  mucous  dis- 
charge. Chromic  acid  cauterization  cured  the  nasal  affection  and 
the  reflex  neurotic  manifestation.    Here  there  was  evidence  of 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES. 


545 


^correlation  between  two  different  portions  of  the  respn-atory 
apparatus,  viz.,  the  nasal  and  laryngeal.  In  those  asthmas,  the 
exciting  cause  of  which  is  to  be  traced  to  nasal  disease,  the 
correlated  tract  is  somewhat  lower  down,  viz.,  in  the  trachea  and 
bronchi,  as  indicated  by  the  characteristic  spasms. 

The  fact  that  cough  often  ensues  on  touching  the  nasal  mucous 
membrane  by  probes,  catheters,  and  instruments  used  for  diagnostic 
purposes,  led  ^^John  Mackenzie  to  conclude  that  many  cases  of 
cough  might  be  of  a  nasal  reflex  character  ;  he  accordingly  con- 
ducted a  series  of  experiments  with  a  view  to  testing  the  sensibility 
and  relative  irritability  of  the  nasal  lining  in  health  and  disease. 
As  a  result  of  these  investigations,  he  concludes  that  there  exists 
a  well-defined  sensitive  area  situated  near  the  posterior  extremity 
of  the  inferior  turbinated  bone  and  contiguous  portion  of  the 
septum  ;  stimulation  of  this  area,  either  through  a  local  patho- 
logical process  or  through  the  action  of  an  irritant  introduced 
from  without,  is  '  capable  of  producing  an  excitation  which  finds 
its  expression  in  a  reflex  act,  or  series  of  reflected  phenomena,'  of 
which  the  most  common  is  nasal  cough.  Hack,  however,  con- 
siders that  the  most  sensitive  region  is  the  anterior  portion  of  the 
inferior  meatus.  Since  the  last  edition  I  have  lately  had  under 
my  care  upwards  of  twenty  cases  of  hypersesthetic  rhinitis  (hay- 
fever  and  pseudo-hay-fever),  in  which  the  characteristic  symptoms 
subsided  on  the  removal  by  the  nasal  trephine  of  prominent 
sensitive  spurs  at  the  anterior  part  of  the  septum.  In  health 
this  area  only  responds  to  some  abnormal  irritation,  and  its 
function  is  doubtless  to  warn  the  lower  respiratory  region  of  the 
approach  of  dangerous  gases  or  other  injurious  agents.  When, 
therefore,  we  are  dealing  with  cases  of  cough,  aphonia,  laryngeal 
spasm,  and  asthma,  it  is  our  duty  not  only  to  examine  the 
lungs  and  larynx  in  seeking  for  the  cause  of  the  symptom,  but 
we  must  also  explore  the  naso-pharynx  and  nares.  And  in  case 
no  obvious  cause  is  found  in  these  regions  we  must  not  forget  to 
include  the  ear  in  our  investigation.  I  have  seen  cases  in  which 
simple  impaction  of  wax  was  the  cause  of  distressing  laryngeal 
symptoms. 

Epileptiform  neuroses,  including  vertigo,  which  we  have  already 
considered  in  relation  to  the  larynx,  occasionally,  but  more  rarely, 
occur  in  connection  with  nasal  disease.  In  the  case  of  Mr.  T., 
which  has  been  related  at  page  526,  a  pinch  of  snuff,  taken  four 
or  five  years  previously  to  my  seeing  him,  had  had  the  effect  of 
causing  him  '  to  drop  dead  down  on  the  floor  in  a  minute.'  This 
had  occurred  once  before  in  early  life ;  but  he  had  forgotten  it  on 

35 


546 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  second  occasion,  until  the  circumstance  of  its  repetition  forcibly- 
recalled  it  to  his  memory.  Cases  of  nasal  polypi  causing  this 
symptom  are  comparatively  rare  ;  but  an  Italian  author,  ^^De 
Gennaro,  has  recently  reported  one. 

^^Bobone,  of  Prazzi,  has  also  lately  called  attention  to  a  patient  who  suffered  periodically 
from  spasmodic  attacks  of  sneezing  of  a  most  violent  nature  ;  on  two  occasions  the  attacks 
of  sneezing  followed  so  rapidly  that  the  patient  became  cyanosed  and  collapsed,  and 
almost  died.  With  the  supervention  of  vertigo,  the  attack  was  cut  short.  Examination 
of  the  nose  showed  a  hypertrophic  condition  of  the  mucous  membrane.  The  rede:: 
symptoms  disappeared  on  treating  this,  the  local  disease. 

Here,  no  doubt,  a  reflex  spasm  of  the  glottis  leads  to  vertigo 
in  the  way  previously  mentioned  when  speaking  of  the  laryngeal 
analogue.  Allusion  has  already  been  made  to  naso-pharyngeal 
catarrh  as  a  predisposing  cause  of  laryngismus  stridulus,  and  the 
rationale  of  the  connection  is  afforded  by  reflex  as  well  as  by 
direct  cause. 

A  case  of  epilepsy,  which  was  said  to  have  been  cured  by 
treatment  of  a  co-existent  nasal  affection,  lately  came  under  my 
notice.  ^^Richardson  and  others  have  also  reported  similar 
examples.  In  most  of  these  instances,  antecedent  epileptic  pro- 
clivities were  probably  aggravated  by  the  supervention  of  nasal 
irritation,  and  the  cure  of  the  latter  merely  removed  a  prominent 
exciting  cause  of  the  former ;  but  others  are  very  possibly  an- 
alogous to  the  epileptiform  seizures  associated  with  laryngeal 
spasm.  I  have  further  knowledge  of  at  least  three  cases  of  mania 
occuring  in  connection  with  nasal  polypus.  In  one  removal  of 
the  growth  was  followed  by  direct  relief  of  the  mental  disorder, 
and  the  patient  was  discharged  from  the  asylum  to  which  he  had 
been  removed.  This  occurred  in  the  practice  of  my  colleague. 
Dr.  Orwin,  but  two  others  happened  recently  in  my  own  ex- 
perience. In  addition  to  the  foregoing  neuroses,  which  are 
now  pretty  generally  recognised  by  specialists  in  this  country  and 
America  as  fairly  often  of  nasal  origin,  there  are  others  to  which 
attention  has  been  drawn  by  Continental  observers,  in  a  manner 
that  may  appear  to  savour  of  exaggeration.  Thus  Hack  believes 
that  megrim,  supra-orbital  neuralgia,  diffuse  headache,  oedematous 
conditions  of  the  nose  and  conjunctivae,  are  almost  invariably  nasal 
in  origin,  and  can  be  cured  by  galvano-caustic  applications  to  the 
turbinated  bodies. 

The  following  case  bears  on  these  points  : 

Mrs.  A.,  aged  51,  consulted  me,  April  25,  1887,  on  account  of  intense  occipital  headache 
which  extended  to  the  shoulders,  and  was  accompanied  by  a  sensation  of  extreme  cerebral 
fulness  and  pressure,  and  constant  drowsiness.  This  condition  had  existed  for  four  years,  and 
had  been  exaggerated  at  the  menstrual  periods  ;  but,  though  the  catamoenia  had  now  ceased 
for  a  year,  exacerbation  still  occurred  at  regularly  recurring  monthly  epochs.   I  should  have 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES. 


b47 


been  inclined  to  set  down  these  symptoms  as  neurosal  complications  connected  with  the 
menopause,  but  that  the  patient  reported  also  that  for  ten  years  she  had  been  unable  to 
blow  the  left  nostril,  that  she  had  a  feeling  of  numbness  over  the  region  of  the  nose,  and 
that  for  the  same  period  she  had  experienced  great  oppression  whenever  she  was  in  a  hot 
room,  which  was  always  relieved  on  her  going  into  the  open  air.  On  examining  the  left 
nostril,  multiple  polypi  were  discovered  in  the  middle  meatus.  These  were  removed, 
and  the  cautery  afterwards  applied.  As  a  result,  all  the  head  symptoms  have  been  relieved 
with  a  promptness  and  completeness  that  is  hardly  credible, 

^^Sommerbrodt,  ^^Heryng,  ^"^Fraenkel,  ^^Schafer,  and  ^^Baratoux, 
have  reported  cases  in  support  of  Hack's  views.  The  first  two 
give  instances  of  spasm  of  the  glottis,  which  may  be  placed 
in  the  same  category  ;  while  Hering  and  "^^Jacobi  hold  that  some 
examples  of  chorea  should  be  likewise  included.  ^^Bosworth 
takes  an  even  more  pronounced  view  than  the  observers  whom 
I  have  quoted,  and  goes  the  length  of  saying  '  that  during  the 
last  four  years  he  has  seen  no  single  case  of  spasmodic  asthma  in 
which  the  source  of  the  disease  could  not  be  traced  to  the  exist- 
ence of  some  disease  in  the  nasal  cavity  ;'  while  in  another  recent 
contribution  he  will  acknowledge  no  form  of  catarrhal  laryngitis 
except  as  a  result  of  nasal  disease,  and  this  not  by  continuity  of 
tissue. 

^^Farquhar  Matheson  has  drawn  attention  to  the  fact  that 
stammering  and  stuttering  frequently  result  reflexly  from  irritation 
in  the  nose  and  naso-pharynx.  My  personal  experience  confirms 
this  connexion. 

In  addition  to  headache,  which  all  rhinologists  have  been  long 
familiar  with  in  connection  with  nasal  catarrh  and  stenosis,  ^"Guye, 
of  Amsterdam,  two  years  ago,  described  another  frequent  symp- 
tom, namely,  a  condition  of  inability  to  fix  the  attention  and 
hampering  of  the  cerebral  functions,  which  is  especially  marked 
in  children  with  naso-pharyngeal  obstructions.  Guye  has  given 
the  name  of  aprosexia  to  this  condition,  so  common  in  the  sup- 
posed victims  of  '  over-pressure.'  ^^Hill  confirms  Guye's  observa- 
tions, especially  as  regards  the  disappearance  of  aprosexia  on  the 
removal  of  adenoid  growths  and  enlarged  faucial  tonsils,  and 
moreover  has  found  that  lymphoid  tonsillar  obstructions  of  the 
nose  and  throat  are  very  prominent  in  the  aprosexic,  backward 
and  idiotic  children  at  Earlswood  Asylum.  "^^Spicer  has  also  called 
attention  to  derangement  of  temper,  energy,  spirits,  and  intellectual 
power  in  connection  with  the  same  stenotic  conditions.  It  is 
believed  that  aprosexia  is  due  to  lymph  stasis  and  venous  stagna- 
tion in  the  intra-cranial  structures,  especially  in  the  frontal  lobes, 
from  the  pressure  of  lymphoid  hypertrophies  in  the  nose  and 
pharynx. 


548 


DISEASES  OF  THE  THROAT  AND  NOSE. 


So  early  as  1881  ^^Guye  mentions  that  Professor  Snellen,  struck 
by  the  frequent  coincidence  of  the  so-called  follicular  conjunctivitis 
with  nasal  and  pharyngeal  adenoid  vegetations,  thought  it  likely 
that  the  diseased  state  of  the  nasal  mucosa  might  have  an 
influence  on  the  conjunctiva,  either  by  producing  irritation  and 
lachrymation  of  the  eye  by  reflex  action,  or  perhaps  through  the 
direct  connection  of  the  lymphatic  systems  of  both  mucous  mem- 
branes. Acting  on  this  view,  he  had  advised  a  young  lady,  aged 
fifteen,  who,  suffering  from  both  these  conditions,  consulted  him 
on  account  of  her  eyes,  to  undergo  treatment  for  her  throat 
and  nose  at  the  hands  of  Dr.  Guye,  prognosticating  that  when 
these  were  cured  the  eyes  would  get  all  right  of  themselves. 
Guye  was  sceptical  of  this  prediction,  but  in  the  result  its  correct- 
ness was  proved. 

^^Cheatham  of  Louisville  has  reported  several  cases  of  diseases 
of  the  eye,  which  he  considered  due  to  nasal  reflex,  and  which 
have  only  been  cured  after  successful  treatment  of  the  con- 
comitant nasal  lesion.  This  observer  also  states  that  'certain 
cases  of  glaucoma  have  been  relieved  by  stretching  the  nasal 
branch  of  the  fifth  nerve,  and  these  cases  might  not  improbably 
be  the  result  of  chronic  nasal  disease.'  The  following  case  in  my 
practice  is  confirmatory  of  the  suggestion  ; 

Mrs.  D.,  aged  30,  from  Canada,  when  consulting  me  in  the  spring  of  1885  regarding  her 
daughter,  told  me  that  she  herself  was  suffering  from  severe  and  increasing  glaucoma, 
for  which  she  had  had  the  best  advice  in  the  Metropolis  and  on  the  Continent.  Iridectomy 
had  been  performed  on  one  eye,  but  without  benefit.  The  pain  was  so  intense  that  she 
was  almost  constantly  applying  cocaine  to  an  extent  that  was  seriously  injuring  her  health. 
Early  in  l886  this  lady  was  attacked  with  double  pneumonia,  followed  by  asthma,  for 
which  she  was  treated  in  my  absence  from  home  by  my  colleague,  Mr.  Percy  Jakins.  On 
recovery,  it  was  found  that  she  was  suffering  from  polypi  in  both  nostrils ;  these  I 
completely  eradicated  after  some  ten  or  twelve  sittings.  In  July,  1886,  she  left  England 
to  reside  in  Jersey,  and  I  did  not  see  her  again  until  quite  recently  (May,  1887).  I  was 
gratified  to  find  that  not  only  were  her  nostrils  free  from  recurrence  of  the  growth,  and 
that  she  had  had  no  return  of  her  asthma,  but  that  her  eyes  were  entirely  free  from  pain, 
and  that  her  sight  had  greatly  improved.  This  change  in  her  ophthalmic  symptoms  had 
taken  place  without  any  further  treatment  of  the  eyes,  and,  as  she  herself  suggested,  had 
dated  from  the  cure  of  her  nasal  disease. 

A  valuable  contribution  has  recently  been  made  on  this  subject 
of  the  connection  of  some  eye  affections  with  nasal  disease  b}' 
*7A.  Bronner,  of  Bradford,  who,  as  practising  rhinology  as  well  as 
ophthalmology  at  a  large  hospital,  is  well  qualified  to  form  a 
correct  opinion  as  to  the  prevalence  of  this  connection.  Accord- 
ing to  this  observer,  hypertrophic  rhinitis  and  other  abnormal 
conditions  of  the  nasal  mucosa  proper  {i.e.,  excluding  the  lining 
of  the  sinuses)  are  frequent  antecedents  of  epiphora,  mucocele, 
inflammation  of  the  conjunctiva  and  cornea,  ulceration  of  these 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES.  549 


same  parts,  granular  lids,  muscular  asthenopia,  and  glaucoma. 
Many  of  these  symptoms  are  due  to  stenosis,  partial  or  complete, 
of  the  nasal  duct.  Suppurative  catarrh  of,  and  growths  in,  the 
antrum  may  in  some  cases  cause  dimness  of  vision  and  contracted 
field,  orbital  neuralgia,  and  glaucoma.  That  empyema  and 
growths  of  the  frontal  sinuses  may  result  in  orbital  symptoms  has 
long  been  recognised  on  account  of  proximity.  Some  of  these 
ocular  and  orbital  complications  of  rhinal  lesions  are  due  to 
obstruction  of  the  nasal  duct,  others  to  venous  stagnation  and 
congestion,  others  to  abnormal  reflexes.  Of  thirty-eight  cases  of 
mucocele  reported  by  ^^Gruhn  and  thirty-five  by  ^^Faravelli  de 
Kruch,  the  nose  was  also  affected  in  thirty-six  and  thirty  cases  re- 
spectively. ^^Ziem  has  drawn  attention  to  the  fact  that  in  most 
cases  of  granular  lids  there  is  also  rhinitis,  and  believes  the  nasal 
lesion  to  be  causal  rather  than  casual. 

I  have  heard  it  stated  by  ophthalmic  surgeons  that  this  inti- 
mate relationship  of  diseases  of  the  eye  and  nose  has  been  grossly 
exaggerated  by  rhinologists,  but  now  that  their  attention  has 
been  drawn  to  it  by  so  many  independent  observers,  and  re- 
cently by  so  distinguished  an  Enghsh  specialist  as  ^^Henry  Power, 
it  behoves  them  to  examine  the  nares  in  all  those  aftections  of 
the  eye  in  which  nasal  disease  is  asserted  to  be  even  an  occasional 
factor  of  causation. 

The  position  taken  by  the  generality  of  oculists  on  this  question 
bears  analogy  to  that  assumed  many  years  since  by  general 
physicians  when  the  question  of  a  primary  pharyngeal  or  laryngeal 
tuberculosis  was  first  mooted.  The  truth  of  such  a  circumstance, 
then  denied,  is  now  no  longer  disputed,  even  by  those  unfamiliar 
with  the  laryngoscope. 

The  question  naturally  arises — is  an  abnormal  state  of  the 
nasal  mucous  membrane  a  frequent  or  only  an  occasional  factor  of 
these  numerous  and  varied  maladies  ?  Before  answering  this 
question  we  must  decide  whether  the  fact  of  relief  or  cure  by 
galvano-caustic  applications  necessarily  implies  that  in  the  nasal 
condition  we  have  a  universal  fons  et  origo  maloriim.  Are  not 
neurotic  disturbances  often  benefited  by  strong  counter-irritation, 
applied  at  the  most  diverse  sites  ?  ^-McBride,  taking  this  line 
of  argument,  goes  so  far  as  to  say  that  a  galvano-caustic  applica- 
tion to  a  healthy  nasal  membrane  *  may  act  just  as  a  counter- 
irritant  of  equal  severity  applied  to  another  part  of  the  body.' 

Reviewing  all  the  facts,  we  must  acknowledge  that  in  many 
instances  asthma  and  other  neuroses  are  excited  by  nasal  lesions, 
and  can  be  cured  by  galvano-cautery  or  other  appropriate,  and 


DISEASES  OF  THE  THROAT  AND  NOSE. 


not  necessarily  caustic,  intra-nasal  therapeutic  agents.  It  is 
possible  also  that  in  a  few  instances  galvano-caustic  applications 
to  the  nose  may  relieve  neurotic  symptoms,  not  of  direct  nasal 
origin,  by  the  inhibitory  action  known  as  counter-irritation,  even 
where  there  is  no  marked  nasal  abnormality.  But  while  person- 
ally inclined  to  agree  with  the  view  that  a  certain  proportion  of 
cases  of  asthma,  megrim,  epilepsy,  and  allied  conditions,  un- 
associated  with  obvious  nasal  lesions,  may  be  cured  by  intra-nasal 
treatment,  I  am  bound  to  say  that  in  my  own  practice  I  have 
seen  not  a  few  instances  of  asthma,  etc.,  which  were  apparently  a 
direct  result  of  existing  nasal  polypi,  but  in  which  the  neurotic 
symptoms  have  continued  in  spite  of  complete  restoration  to 
health  of  the  nasal  mucous  membrane.  In  such  a  case  it  is  fair 
to  suppose  that  although  the  peripheral  nasal  lesion  was  apparently 
an  exciting  agent  of  respiratory  disturbance,  the  real  disease  was 
central  in  its  origin,  and  probably  due  to  lowered  resistance  or 
increased  excitability  of  the  medullary  ganglia.  In  other  words 
asthma  is  not  in  itself  a  nasal  disease,  although  it  may  exhibit 
nasal  complications,  and  may  sometimes  yield  to  intra-nasal 
treatment.  ^^Schmiegelow,  of  Copenhagen,  in  a  recent  work  of 
great  merit,  lays  down  some  good  rules  with  regard  to  the  con- 
nection of  the  asthmatic  phenomenon  with  the  nose,  which  on  the 
whole  we  have  found  to  accord  with  our  own  experience.  The 
connection  may  be  assumed — (i)  when  the  clinical  picture  leads 
to  the  belief  that  the  abnormal  condition  of  the  nasal  cavities  is  a 
factor  in  the  production  of  the  asthmatic  attack,  which  is  to  be 
inferred  when  the  asthmatic  symptoms  occur,  or  are  aggravated 
with  any  increase  in  the  nasal  symptoms  ;  (2)  when  local  treat- 
ment, such  as  pencilling  the  nose  with  cocaine,  the  introduction  of 
tampons  of  cocaine  or  menthol  arrests  the  symptoms,  or  local 
treatment  gives  immediate  relief;  (3)  when  the  careful  treatment 
of  peripheral  irritation,  due  to  a  chronic  nasal  catarrh,  definitely 
checks  the  asthmatic  attack.  At  the  same  time,  as  Schmiegelow 
very  properly  remarks,  '  nasal  diseases  may  accidentally  accom- 
pany cases  of  asthma  without  having  any  etiological  connection 
with  the  asthmatic  attacks.'  It  is  best  always  to  be  very  reserved 
in  expressing  anything  to  the  patient  as  regards  the  influence 
local  treatment  may  have  upon  the  asthmatic  attacks.  Where 
the  clinical  picture  gives  us  decided  belief  in  a  causal  connection 
between  the  nose  and  the  asthmatic  phenomena,  'it  is  in  these 
cases  only  when  the  patient  himself  wishes  it,  after  he  has  vainly 
tried  every  other  treatment,  that  one  ought  to  begin  the  rhino- 
surgical  treatment ;  but  the  result  will  probably  be  negative  with 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES. 


551 


regard  to  the  asthma,  though  it  may  otherwise  do  the  patient 
some  good  by  curing  his  nose.'  An  anonymous  reviewer  of  this 
author's  volume  pertinently  adds  that  only  by  carefully  selecting 
the  patients  upon  whom  rhino-surgical  treatment  is  really  likely  to 
be  of  service,  shall  we  avoid  the  discredit  of  '  meddlesome 
surgery  '  and  the  reproach  of  Kurz,  that  in  asthma  one  has  to  do 
with  a  real  sufferer  who  is  not  merely  an  appendix  to  his  nose. 

It  would  serve  no  good  purpose  to  enter  at  greater  length 
into  the  varied  reflex  phenomena  connected  with  either  hyper- 
sesthesia,  hypertrophy,  or  hyper-stimulation  of  the  nasal  mem- 
brane ;  but  it  is  an  interesting  fact  to  note  that  the  nasal  reflex 
has  already  been  made  use  of  in  testing  the  local  sensory  action 
of  drugs.  Into  one  nostril  of  a  frog  the  solution  of  the  drug  is 
introduced  drop  by  drop,  at  intervals  of  a  few  minutes  ;  the 
nasal  reflex  is  then  tested  by  passing  a  very  light  wire  into  the 
medicated  nostril,  and  comparing  it  with  the  fellow  of  the 
opposite  side.  Irritation  of  this  the  sound  side  will  cause  a  frog 
to  blink,  wince,  and  make  efforts  to  remove  the  offending  body. 
This  method  has  been  used  to  determine  the  local  differences 
between  caffeine  and  theine,  and  is  very  accurate  and  delicate  ; 
and  the  very  nature  of  these  experiments  suggests  the  appropriate 
remedy  for  hypersesthetic  conditions  of  the  pituitary  membrane. 
From  the  first  introduction  of  cocaine,  I  employed  it  for  the 
relief  of  nasal  reflexes,  in  common  with  many  other  surgeons, 
though  the  effect  of  the  drug  is  not  always  anodyne.  In  my  own 
person,  cocaine  applied  to  the  nostril  produces  spasm,  cough,  and 
nausea.    Where  cocaine  fails,  atropine  often  succeeds. 

The  Accessory  Cavities. — The  frontal,  sphenoidal,  ethmoidal, 
and  maxillary  sinuses  (Fig.  XVIII.,  p.  34)  require  to  be  taken 
into  account  in  studying  nasal  diseases.  These  cavities  com- 
municate by  small  openings  with  the  nasal  fossae,  and  are  lined 
by  a  mucous  membrane  similar  in  structure  to  that  covering  the 
respiratory  area.  They  probably  serve  as  reservoirs  of  warm  and 
:noist  air,  and  thus  aid  in  the  respiratory  function  ;  doubtless, 
however,  their  original  raison  d'etre  was  to  afford  lightness  to  the 
bony  structures  of  the  face.  When  their  openings  into  the  nasal 
fossae  are  blocked  by  swelling  of  the  membrane  or  by  other 
mechanical  causes,  a  retention  of  secretion  results,  which  may 
end  in  abscess,  or  may  lead  to  a  chronic  suppurative  condition  of 
the  lining.  I  have  long  been  in  the  habit  of  pointing  out  that 
one-sided  ozcena  is  most  frequently  due  to  this  circumstance, 
and  ^^published  record  of  the  fact  is  to  be  found  so  far  back  as  1879. 
Suppuration  of  the  accessory  cavities,  especially  of  the  antrum, 


552 


DISEASES  OF  THE  THROAT  AND  NOSE. 


is  rxot,  however,  often  of  catarrhal  origin,  and  is  much  more 
frequently  connected  with  other  causes,  such  as  dental  mischief, 
caries  cf  a  surrounding  portion  of  bone,  a  missile,  or  other  foreign 
body- 

The  naso-pharynx  (Fig.  XV.,  p.  29)  is  often  the  seat  of  various 
forms  of  catarrh,  which  are  sometimes  prijnary,  and  affect  nasal, 
Eustachian,  and  adjoining  regions  by  extension ;  or  the  inflam- 
mation may  be  secondary  to  disease  in  these  latter  regions,  as 
when  a  suppurative  catarrh  of  the  middle  ear  or  of  the  accessory 
sinuses  discharges  into  the  upper  pharynx. 

Many  3^ears  ago  Luschka,  in  describing  the  pharyngeal  tonsil 
to  be  presently  alluded  to,  drew  attention  to  a  depression  or 
crypt  situated  usually  towards  the  lower  part  of  the  tonsil,  which 
was  somewhat  larger  and  more  defined  than  neighbouring  crypts, 
and  w^hich  ended  as  a  dilated  extremity  or  pouch.  This  pouch, 
though  not  a  constant  structure,  is  frequently  present,  and  has 
since  been  known  as  '  Luschka's  bursa.'  It  is,  no  doubt,  a  vestige 
of  the  communication  which  exists  during  a  portion  of  foetal  life 
between  the  phar3mx  and  the  hypophysis  cerebri. 

^^Tornwaldt  of  Dantzig,  who  has  made  an  extensive  series  of 
observations  concerning  catarrh  of  this  pouch,  regards  it  as  a 
potent  etiological  factor  in  the  production  of  post-nasal  and 
Eustachian  catarrh,  pharyngitis,  laryngitis,  etc.  In  fact,  he 
asserts  that  these  bursal  affections  are  to  be  found  in  so  large  a 
proportion  as  20  per  cent,  of  all  diseases  of  the  naso-pharynx. 
He  also  considers  that  this  pharyngeal  bursitis  is  often  a  sequel, 
not  only  of  common  catarrh,  but  also  of  scarlatina,  variola, 
diphtheria,  etc. 

For  my  own  part,  I  beheve  that  the  importance  of  this  non- 
constant  structure  has  been  much  exaggerated.  For  some  time 
I  have  been  endeavouring  to  confirm  Tornwaldt's  observations ; 
but  only  very  occasionally  have  I  found  any  large  catarrhal  cavity 
into  which  I  could  insert  a  galvano-cautery  point,  this  being  the 
'  radical,  active,  and  certain '  treatment  recommended  by  him. 

The  post-nasal  space  may  be  blocked  by  polypi,  cysts,  and 
hypertrophied  turbinals  projecting  from  the  nasal  cavities  proper, 
or  by  fibroid  and  malignant  tumours  from  the  roof  of  the  naso- 
pharyngeal area.  But  by  far  the  most  common  affection  is 
hypertrophy  of  the  pharyngeal  or  Luschka's  tonsil  (Fig.  LV., 
p.  86),  to  which  ^^Meyer  of  Copenhagen  first  directed  attention, 
and  which,  called  by  him  adenoid  growths  or  post-nasal  vegeta- 
tions, are  now  generally  recognised  under  those  terms. 

This  overgrowth  of  the  normal  adenoid  tissue  of  the  pharyngeal 


ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES. 


553 


vault  is  very  frequently  associated  w^ith  enlargement  of  the  faucial 
tonsil,  with  w^hich  it  is  analogous,  and  is  usually  met  with  between 
the  periods  of  childhood  or  even  infancy  and  adolescence.  The 
symptoms  to  which  it  gives  rise  and  its  appropriate  treatment  will 
be  considered  at  length  in  the  next  chapter. 

Setting  aside  all  theorizing,  the  following  summary  concisely 
represents  the  various  circumstances,  some  symptomatic  and 
some  resultant,  of  the  two  great  classes  of  nasal  diseases,  viz., 
hypertrophy  and  atrophy  of  the  nasal  structures,  the  first  leading 
to  obstruction,  the  second  to  undue  patency  of  the  choanae,  and 
both  associated  with  disorders  or  abrogation  of  function. 

In  obstruction  of  the  nose  and  naso-pharynx,  any  or  all  of 
the  following  objective  characteristics  may  be  observed,  i  to  6 
being  the  most  common  : 

1.  Mouth-breathing,  with  the  characteristic  dropped  jaw,  and  a 

dry  mouth  in  the  morning. 

2.  A    peculiar  physiognomy,  due  to   pinched,  collapsed,  and 

dimpled  alge  nasi,  often  associated  with  a  wideness  of 
the  bridge  of  the  nose,  together  with  oedema  and  dilated 
veins  about  the  root,  the  inner  canthi  being  also  drawn 
down. 

3.  Noisy  respiration  in  the  day  and  snoring  at  night.    In  some 

instances  children  wake  up  '  fighting  for  their  breath.' 
A,  A  bnormalities  of  secretion,  occasionally  complicated  by  lachry- 
mation   and   epistaxis,  and  sometimes   causing  eczema 
narium  and  herpes.    The  secretions  are  only  exceptionally 
malodorous. 

5.  Vocal  impairment.    This  is  either  of  the  nature  of  want  of 

resonance,  deadness  of  speech,  or  inability  to  pronounce 
correctly  the  letters  m  and  n,  or  to  take  the  upper  notes  in 
singing.  Associated  with  the  foregoing  may  be  included 
vocal  fatigue. 

6.  Various  morbid  conditions  of  the  pharynx,  larynx,  and  bronchi, 

with  sore  throat,  hoarseness,  cough,  and  dyspnoea. 

7.  Many  morbid  conditions  of  the  ear,  including,  according  to 

some  authorities,  even  deaf-mutism. 

8.  Chest  deformities,  accompanied  by  collapse  of  the  apical  or 

other  portions  of  the  lungs. 

9.  Hernia,  from  straining  in  efforts  to  free  the  nose  from 

obstruction. 

10.  Aprosexia,  inability  to  concentrate  attention,  backwardness 
and  stupidity,  with  megrim,  derangement  of  sleep,  temper, 
spirits  and  energy  ;  melancholia. 

11.  Sneezing  and  reflex  neuroses,  including  asthma,  epilepsy, 
chorea,  convulsions,  stammering  and  stuttering,  aphonia, 
whooping-cough. 

12.  Red  nose,  facial  erysipelas,  oedema  of  the  nose  and  con- 
junctiva, glaucoma,  and  other  eye  lesions;  goitre:  lingual 
varix,  globus. 


554 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Nasal  Stenosis  may  be  subjectively  evidenced  by  many  or  even 
a.11  of  the  following  conditions  : 

1.  A  feeling  of  stuffiness  in  the  nose  and  head,  and  occasionally, 

as  in  polypus,  the  sensation  of  a  foreign  body. 

2.  A  sensation  of  dry^iess  in  the  mouth  and  throat,  especially  on 

v^aking  in  the  morning. 

3.  Headache,  especially  on  mental  application.    In  some  cases 

there  is  frontal  pain,  accompanied  by  throbbing. 

4.  Sore  throat 

5.  Anosmia,  Parosmia,  and  impairment  of  taste. 

6.  Disorders  of  common  sensation  (hypersesthesia  or  anaesthesia). 

7.  Asthenia,  with  either  lassitude,  restlessness,  depression,  or  loss 

of  energy  and  spirits  (aprosexia). 

8.  A  feeling  either  of  chilliness  or  feverishness. 

9.  Deafness  and  tinnitus. 

In  atrophic  conditions  there  are  usually  present : 

1.  Diminished  secretion  and  crusts  on  the  mucous  membrane. 

2.  Ozsena. 

3.  Exaggerated  nasal  respiration. 

,  4.  Wide  alas,  with  narial  orifices  markedly  open  and  often 
nearly  vertical,  the  tip  of  the  nose  being  uptilted  and 
the  bridge  frequently  depressed. 
5.  Atrophic  or  dry  catarrh  of  the  pharynx,  middle  ear,  and  even 
larynx. 


REFERENCES  TO  AUTHORITIES. 


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NAME. 

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534 

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Graham. 

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534 

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W.  Ogle. 

Med.-Chir.  Trans. ^  vol.  liii.,  p,  289.  1870. 

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Klein. 

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536 

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John  N.  Mackenzie. 

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537 

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MORGAGNI. 

537 

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TOYNBEE. 

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KOHLRAUSCH. 

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537 

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BiGELOW. 

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BOSWORTH. 

Trans.  Internat.  Congj-ess,  p.  328.    188 1. 

537 

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1  > 

^ Nezu  York  Med.   /^ourn.,  April  24  and 
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/  Diseases  of  the  Nose   and  Throat,  vol.  i. 

537 

14 

1 J 

\    New  York,  1889. 

538 

Morell-Mackenzi  \l. 

Op.  cit.,  vol.  ii.,  p.  372. 

538 

\l 

ASCHENBRANDT. 

/  Ueberdie  Bedeiitiing  der  Nase  im  Respira- 
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539 

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(Archives  of  Otology,  vol.  xvii.,  No.  4. 
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540 

MacDonald 

K  The  Respiratory  Functions  of  the  Nose. 
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ETIOLOGY  AND  PATHOLOGY  OF  NASAL  DISEASES. 


555 


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NO. 

NAME. 

TITLE  OF  work  REFERRED  TO. 

541 

19 

(Archives  of  LaryngoL,  vol.  iii.,  p.  240 
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541 

20 

John  N.  Mackenzie. 

Medical  Nenis,  Oct.,  1884. 

541 

21 

WOAKES. 

Op.  cit. 

543 

22 

BOSWORTH. 

Loc.  cif.,  p.  329. 

514 

W   H   Dai  y 

/ Hay  AstJuna,  etc.,  in  Archiv.  of  LaryngoL 
1     p.  157,  vol.  iii.    New  York,  1882. 
\journ.  Amer.  Med.  Assoc.,  Sept.,  1883. 

544 

24 

KOE. 

-!  Pathology  and  Cure  of  Hay  Fever.  New 

(    York,  1883  and  1884. 

r  Ueber  ein  operative  Radical- Behandhiiig 
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544 

25 

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-f     Asthma,  Heufieber,  soivie  zahrlreicher 

verwandter  Frscheimmger.  Frieburg, 

544 

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26 

John  N.  Mackenzie. 

Amer.  Journ.  Med.  Scietices,  ]u\y,  1883. 

544 

27 

Lennox  Browne. 

British  Med.  Jojirnal,  June  21,  1884. 

544 

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VOLTOLINI. 

/  Galvano  Katistic,%.  246,  u.  312.  Breslau, 
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544 

Predborski. 

/  Gazeta    Lekarska,  quoted  in  Jcuni.  of 
\    Laryngology.    Jan.,  1 887. 

545 

30 

John  N.  Mackenzie. 

Loc.  supra  cit.  (25). 

546 

31 

De  Gennaro. 

[Archiv.  Ital.  Laringol.,  fasc.  3  and  4. 
1    An.  vi.,  1886. 
Bolletino  Prazzi,  July,  1886. 

546 

32 

BOBONE. 

546 

33 

B.  W.  Richardson. 

Asclepiad,  Jan.,  1887. 
(Berlin  Klin.  Wochejischrift,  10  and  1 1, 
\    1884;  and  10  and  11,  1885. 

547 

34 

*>\OiVnV/TFR  ■RRonT 

OV-'iVl  iVi  Il(  J\.  JJlS.Wi^  X  • 

547 

1  c 

Heryng. 

/ Annates  Mai.  du  Larynx,  etc.,  2  and  t^, 
\  1886. 

547 

Fraenkel. 

^Berlin  Klin.  Wochenschrift,  16  and  17, 

t    1 88 1  ;  and  28,  1884. 

/Quoted  in  an  interesting  lecture  by  McBride, 

547 

37 

Schafer.  j 

547 

38 

Baratoux.  ) 

\    Brit.  Med.  /ourn.,  Jan.  29,  1887. 

547 

39 

Jacobi. 

Lnterjiat.  Journ.  Med.  Sciences, K'^xW,  1886. 
Netv  York  Med.  Journ.,  October  18,  1884. 
Brit.  Med.  Journ.,  vol.  ii.,  1888,  p.  487. 

547 

40 

BOSWORTH. 

547 

41 

Farquhar  Matheson. 

547 

GUYE. 

(Journal  of  Laryngology,  vol.  iii.,  No.  12, 
\    Dec,  1889. 

547 

43 

Hill, 

British  Med.  Jozirnal,  Sept.  28,  1889. 

547 

44 

ScANES  Sl'ICER. 

Lbid.,  Sept.  14,  1889. 

548 

45 

GUYE. 

(Trans,  hitertiat.  Med.  Cong.,  1 881,  vol 

\    iii.,  p.  290. 

548 

46 

Cheatham. 

American  Practitioner,  April  2,  1887. 

47 

( Journal  of  Laryngology,  vol.  iii..  No.  12. 
\    Dec,  1887. 

40 

(  Centralblatt  fiir  Augenheilkunde,  p,  438, 
\  1888. 

549 

49 

Faravelli  de  Kruch. 

Annates  d" Opthalmol.,  vi.,  1887. 

549 

ZlEM. 

( Allgemeine  Med.  Cent.  Zeit.,  Nos.  20  and 
\  23,1886. 
Year  Book  of  Treatment,  1 889. 

549 

51 

Henry  Power. 

McBride. 

T  /ir     ^u-H'V/i  /*?/ 

550 

53 

Schmiegelow. 

(Asthma  Considered  Specially  in  Relation 
\    to  Nasal  Disease.    London,  1890. 
Brit.  Med.  Journ.,  vol.  i.,  1879,  P-  371- 

551 

54 

Lennox  Browne. 

552 

55 

Tornwaldt. 

(Ueber  die  Bedezttung  der  bursa pharyiigea, 
\    etc    Wiesbaden,  1885. 

552 

56 

Meyer. 

( Hospitals  Tidende,  Nov.,  1868  ;  and  Med.- 
\     Chir.  Trans.,  vol.  liii.     London,  1870. 

CHAPTER  XXV. 


DIAGNOSIS  AND  TREATMENT  OF  INTRA-NASAL  AND 
NASO-PHARYNGEAL  DISEASES. 

The  following  may  be  taken  as  a  good  working  classification  of 
the  various  morbid  conditions  of  the  intra-nasal  cavities ;  in  the 
succeeding  sections,  to  avoid  reiteration,  it  is  only  approximately 
followed,  and  to  some  of  the  rarer  diseases  simple  allusion  is 
all  that  appears  necessary.  Those  divisions  printed  in  black  type 
indicate  the  commoner  groupings  and  those  of  greatest  importance. 


A.  NASAL  CAVITIES. 


I.  Morbid  conditions  of  the 
mucous  membrane. 


Acute  Rhinitis,^ 


II.  Morbid  conditions  of  the 
osteo-cartilaginous  frame- 
work and  Septum. 


Chronic 
Rhinitis. 


/Hsematoma. 
Abscess. 


Perforations. 


Narrowing. 
Deviations  and 

Deformities. 
Hypertrophies 

or  Spurs. 


(a.  Simple,  or  non-specific. 

b.  Specific  —  usually  purulent  —  (in 

fevers,  diphtheria,  syphilis, 
gonorrhoea,  glanders,  etc.). 

c.  Neurotic— '  hay-fever,' or 

periodic  hypei-iBsthctic  rhinitis, 
and  pseudo  hay-fever. 
a.  Simple. 

!(  Cavernous. 
J  Mucoid. 
Simple^  Lymphoid. 
V.Glandular. 
■Rhinoscleroma. 
rSimple. 

I  Specific  (struma, 

syphilis,  tubercle, 
I,    lupus,  lepra). 
Rhinitis  Caseosa. 


(Specific)- 


Atrophic 


Non-specific. 
Specific. 


Fevers. 
Syphilis. 
Struma. 
Lupus. 
^  Lepra. 


Developmental,  etc. 
Traumatic. 
Cartilaginous. 
Osteo-cartilagiaous. 


Necrosis  and  Caries — Ethmoiditis. 
^Synostosis- 


ACUTE  RHINITIS. 


557 


III.  New  growths  (whether  of 
mucous  membrane,  bone, 
or  cartilage). 


Non-mah'gnant  (Polypi) 


IV.  Epistaxis. 


V.  Neuroses. 


VI.  Foreign  Bodies. 


B. 


ACCESSORY 
CAVITIES, 


including 


c. 


NASO-PHARYNGEAL 
CAVITY. 


Malignant 


r  Mucous,  myxoma. 
<  Myxo-fibroma. 
\^  Fibroma. 

Cystoma. 

Papilloma. 

Enchondroma. 

Osteoma. 

Exostosis. 

(Sarcoma. 
Cylindroma- 
Carcinoma. 


Of  Olfactory  Nerve. 

Of  Fifth  Nerve. 
Of  Facial  Nerve. 
/Physical  : — Rhinoliths,  etc. 
\  Biological  : — Larvae,  etc. 
C  Maxillary  Sinus.  \ 
1  Frontal  Sinuses.  I 
I  Ethmoidal  Sinuses.  ( 


Anosmia. 
Parosmia. 
\  Anaesthesia. 
I  Hyperaesthesia. 
Paresis  of  Alae. 


Catarrh. 
Empyema. 

New  Growths 


Sphenoidal  Sinuses. 
Post-Nasal  Catarrh. — Bursitis. 
Hypertrophy  of  Pharyngeal  Tonsil. 

New  Growths  jSfllant, 


Benign. 
Malignant. 

-Adenoids. 


A.  DISEASES  OF  THE  NASAL  CAVITIES. 

I.    MORBID  CONDITIONS 
OF  THE  MUCOUS  MEMBRANE. 
ACUTE  RHINITIS. 

Acute  rhinitis  may  be  of  {a)  a  simple,  non-specific  nature  ; 
{b)  of  a  specific  variety,  as  when  forming  part  of  a  contagious  fever 
or  a  special  dyscrasia ;  or  (c)  of  a  neurotic  hyperaesthetic  character, 
as  in  the  conditions  known  as  hay-fever  and  pseudo-hay-fever. 
In  each  the  inflammation  is,  as  a  rule,  confined  to  the  nasal 
cavities  in  which  it  first  appears,  but  it  may,  especially  in  its 
specific  varieties,  arise  secondarily  from  the  pharynx,  whilst  in  its 
simple  form  it  may  extend  to  the  pharynx,  middle  ear,  or  larynx ; 
or,  on  the  other  hand,  to  the  cavities  of  the  maxillary,  frontal, 
ethmoidal,  or  sphenoidal  bones.  This  is  especially  true  of  recur- 
rent attacks  of  acute  rhinitis,  in  which  the  acuteness  becomes,  so 
to  speak,  almost  chronic. 

{a.)  Simple  rhinitis  may  be  acute  or  sub-acute.  The  former 
will  be  first  considered. 

Etiology.— Acute  nasal  catarrh  is  popularly,  and  probably  cor- 
rectly, associated  with  exposure  to  cold  and  sudden  changes  of 
temperature,  the  attack  being  often  aggravated  by  the  inhalation 
of  irritating  matters,  such  as  dust  and  chemical  vapours.  Excep- 


558 


DISEASES  OF  THE  THROAT  AND  NOSE. 


tionally,  excessive  heat  causes  acute  catarrh  in  a  neurotic  subject. 
Amongst  predisposing  circumstances,  youth,  and  the  strumous, 
rheumatic  and  neurotic  diatheses  must  be  mentioned.  Epidemic 
catarrh  is  rare  in  this  country,  and  well-authenticated  instances 
where  one  individual  has  '  caught '  cold  from  another  are  rarer 
still.  It  will  be  generally  found  that  such  cases  can  be  explained 
by  reference  to  their  exposure  to  similar  conditions  and  environ- 
ment, and  especially  to  unsanitary  surroundings. 

Pathology. — Little  remains  to  be  added  on  this  head  to  what 
has  been  laid  down  generally  in  the  preceding  chapter.  Vaso- 
motor dilation  of  the  vessels  leads  to  engorgement  of  the  erectile 
cavernous  tissue,  and  to  increased  activity  of  the  serous  and  mucous 
glands,  and  of  the  lymphoid  tissue.  The  muco-serous  secretion 
contains  excess  of  leucocytes,  some  normal  and  others  degene- 
rating into  pus  cells,  with  shed  epithelium  (occasionally),  a  few 
red  corpuscles,  dust  and  molecular  debris,  and  specimens  of  such 
micro-organisms  as  happen  to  be  prevalent  in  the  surrounding 
atmosphere. 

Recent  investigations  into  the  changes  in  the  leucocytes  or 
lymphocytes  indicate  a  considerable  variation  in  size  and  char- 
acter, particularly  with  respect  to  their  reaction,  with  basic  acid 
and  neutral  dyes.  The  nucleus  in  some  appears  single,  and  in 
others  multiple.  The  exact  relationship  of  these  various  con- 
ditions, with  the  types  and  periods  of  rhinitis,  have,  however,  yet 
to  be  established. 

Symptoms  vary  greatly  in  certain  individuals,  and  also  according 
to  the  exciting  cause.  The  first  onset  is  often  characterized  by 
arrest  of  secretion,  irritation  of  the  nostril,  and  sneezing ;  these 
symptoms,  indicating  hypersemia,  are  quickly  followed  by  a  hyper- 
secretion. Instead  of  mere  sneezing,  there  may  be  fever,  suc- 
ceeded by  a  feeling  of  chilliness,  and  rarely,  the  first  symptom 
may  be  a  well-marked  rigor.  Headache  and  fulness,  sometimes 
amounting  to  severe  pain  in  the  frontal  region,  quickly  follow, 
with  not  infrequ^tly  heavy  and  even  painful  sensations  in  the 
muscles  and  joints.  As  the  swelling  of  the  rhinal  mucous 
membrane,  with  its  consequent  uncomfortable  obstruction  to 
nasal  respiration,  increases,  aprosexia  supervenes.  Then  occurs 
a  dry,  and  frequently  sore,  condition  of  the  throat,  due  to  en- 
forced mouth-breathing.  The  paretic  palate  influences  the 
articulation,  giving  the  characteristic  muffled  nasal  tone  to  the 
voice,  which  is  usually  altered  also  in  phonetic  quality  by  sub- 
acute changes  in  the  larynx. 

Lachryrnation  and  deafness,  the  result  of  concomitant  catarrh 


ACUTE  RHINITIS, 


559 


of  the  nasal  duct,  conjunctiva,  and  Eustachian  tube,  and  eczema 
narium  and  redness  of  the  tip  of  the  nose  from  the  irritating  dis- 
charges, are  frequent.  Illustrative  of  a  coincidental  troph-neurotic 
condition,  we  may  often  observe  a  crop  of  alar  or  labial  herpes. 

On  dilation  and  illumination  of  the  vestibule  by  anterior 
rhinoscopy,  the  mucous  membrane  is  seen  to  be  red  and  swollen; 
the  redness,  however,  is  not  invariably  present.  The  tumefaction 
of  the  '  baggy '  inferior  turbinated  body  can,  in  simple  cases,  be 
readily  reduced  by  pressure,  by  application  of  a  weak  solution  of 
cocaine,  the  sniffing  of  spirits  of  camphor  or  menthol,  or  by  the 
mild  application  of  any  form  of  cautery,  chemical  or  thermal ; 
in  this  way  erection  due  to  acute  catarrh  can  be  differentiated 
from  that  of  an  old-standing  hypertrophic  rhinitis,  which  may 
moreover  complicate  it.  The  middle  turbinated  body  will  be  seen 
touching  the  swollen  septal  mucous  membrane,  and  this  oblite- 
ration of  the  '  olfactory  slit '  so  often  observed  is  the  cause  of  the 
anosmia.  On  posterior  rhinoscopic  examination,  when  feasible, 
flakes  and  plugs  of  mucus  can  often  be  made  out  in  the  neigh- 
bourhood of  the  Eustachian  orifices,  in  Rosenmuller's  fossa,  in 
Luschka's  pouch,  and  in  the  choanse.  The  posterior  extremities 
of  the  turbinated  bodies,  especially  of  the  inferior,  will  be  evi- 
dently swollen,  and  will  appear  of  a  deep  red  colour,  unless 
obscured  by  mucus.  In  young  persons  the  pharyngeal  tonsil  will 
appear  red  and  swollen. 

Prognosis  is,  as  a  rule,  favourable.  Extension  to  the  accessory 
cavities  of  a  non-specific  nasal  catarrh  is  rare ;  but  when  due  to 
insanitary  influences,  or  associated  with  acute  infectious  diseases 
— amongst  which  epidemic  influenza  must  not  be  forgotten — 
recovery  may  be  long  delayed,  chronic  catarrh  may  be  engen- 
dered, and  with  it  a  tedious  train  of  symptoms  in  the  way  of 
hypertrophies  and  neoplasms,  atrophy,  and  ozsena. 

Treatment  need  not  occupy  much  space,  because,  although 
each  year  scores  of  new  remedies  are  suggested,  there  are  but  few 
that  hold  their  reputation ;  and  this  for  two  reasons — first,  that 
they  are  given  empirically,  and  without  the  least  regard  to  correc- 
tion of  the  predisposing  factor,  or  recognition  of  the  exciting  cause 
of  an  attack ;  and  secondly,  because,  as  a  rule,  they  are  com- 
menced too  late.  The  physician  being  seldom  consulted  at  the 
time  of  an  acute  coryza,  directions  for  treatment  must  therefore 
be  largely  prophylactic ;  and  prescriptions  for  remedies,  being 
often  given  in  advance  of  recurrence,  must  necessarily  be  of  a 
tentative  character.  The  following  is  an  epitome  of  my  general 
advice  in  such  cases  : 


560 


DISEASES  OF  THE  THROAT  AND  NOSE. 


1.  Prohpylactic.  —  Exercise,  Turkish  baths,  avoidance  of 
draughts  on  the  one  hand,  and  of  over- clothing,  and  especially  of 
retention  of  such  extra  garments  as  cloaks  and  wrappers  within 
doors,  all  suggest  themselves.  A  light  diet,  especially  at  night, 
and  a  regular  daily  action  of  the  bowels,  are  both  measures  to  be 
regarded  as  of  importance  by  the  catarrhally  disposed  subject. 

2.  Medical. — First  Stage:  Local. — For  the  relief  of  the  premoni- 
tory irritation  or  fulness,  anti-catarrhal  smelling-salts  (Form.  116), 
the  use  of  the  chloride  of  ammonium  inhaler  (p.  106),  with  or 
without  addition  of  oxygenating  ingredients  (Form.  41),  and  the 
use  of  an  oro-nasal  inhaler  with  the  inhalants  in  Form.  41,  52,  and 
53,  are  all  and  each  of  service,  but  I  have  for  some  time  now  used 
nothing  but  menthol,  inhaled  by  the  nares  or  applied  by  spray, 
brush,  or  inhaler,  or  where  the  inspiratory  power  of  the  nostrils 
is  for  the  time  actually  abrogated,  by  light  tampons  of  menthol- 
wool. 

It  may  be  convenient  here  to  make  some  remarks  in  detail  on  the  properties  of  this 
remarkable  drug,  to  which  I  have  so  frequently  alluded  in  other  sections  of  this  work. 
Menthol,  which  is  of  the  nature  of  camj^hor,  exerts  its  action  in  the  following  manner: 

1.  It  stimulates  to  contraction  the  capillary  bloodvessels  of  the  passages  of  the  nose 

and  throat,  always  dilated  in  the  early  stages  of  head-cold  and  influenza. 

2.  It  arrests  sneezing  and  rhinal  flow. 

3.  It  relieves,  and  indeed  dissipates,  pain  and  fulness  of  the  head  by  its  pain-killing  and 

astringent  properties,  so  well-known  by  its  actions  when  applied  externally  to  the 
brow  in  cases  of  /zV  douloureux. 

4.  It  is  powerfully  germicide  and  antiseptic.    It  thus  kills  the  microbe  of  infection 

in  many  specific  fevers,  even  when  unaccompanied  by  fever.  It  also  prevents  its 
dissemination. 

The  remedy  may  be  employed  by  means  of  a  general  impregnation  of  its  vapour 
through  a  room  or  house,  or  locally  to  the  nostrils  and  air-passages;  for  both  which  pur- 
Doses  there  are  several  methods: 

[a)  A  10  to  20  per  cent,  solution  of  menthol  in  almond  oil,  in  liquid  vaseline,  or  in  one 

of  the  many  other  odourless  paraffin  compounds,  can  be  sprayed  into  the  nose  or 

throat,  or  about  a  room. 
(/')  By  placing  ten  to  twenty  grains  in  an  apparatus  specially  designed  by  Rosenberg 

for  administering  the  drug  in  cases  of  laryngeal  consumption  by  inhalation,  in  the 

form  of  vapour  mingled  with  steam, 
(r)  By  placing  a  similar  amount  or  one  or  two  drachms  of  the  oily  solution  in  a  Lee's 

steam-draft  inhaler,  or  bronchitis  kettle. 
{d)  By  a  simple  arrangement  of  placing  a  saucer  of  water  containing  a  similar  quantity 

of  the  crystals  over  a  gas-burner  in  the  hall,  by  means  of  which  the  whole  house  is 

kept  constantly  permeated  with  the  drug  during  prevalence  of  an  epidemic. 
{c)  But  by  far  the  most  convenient  method  for  personal  use  is  to  carry  always  the 

ingenious  pocket  menthol-inhaler  known  as  Cushman's,  which  should  be  used  not 

only  then  but  on  the  first  approach  of  an  attack  of  rhinitis,  and  several  times  a  day, 

in  cold-catching  weather  by  those  subject  to  head-colds. 
The  instrument  consists  of  a  glass  cylinder,  four  inches  in  length,  half  an  inch  in 
diameter,  and  open  at  both  ends.    The  tube  contains  crystals  of  menthol  closely  packed, 
and  prevented  from  escape  by  perforated  zinc  and  cork.   The  opening  at  one  end  is  twice 


ACUTE  RHINITIS. 


561 


the  size  of  the  other,  the  larger  behig  intended  for  inhalation  by  the  mouth,  the  smaller 
for  the  nostril.  The  latter  is  the  method  which  I  by  preference  recommend.  It  is  not  to 
be  simply  smelt,  but  well  snifted  or  inhaled,  so  as  to  cause  some  tingling  or  smartness,  a 
sensation  which  is  quickly  followed  by  that  of  coolness,  and  openness  of  the  previously 
'  stuffed  '  and  heated  nostril. 

I  may  add  that  for  all  forms  of  nasal  disease  causing  obstruction  to  the  natural  breath- 
way,  I  have  for  three  or  four  years  largely  prescribed  menthol  by  means  of  direct  appli- 
cation or  inhaler.  By  its  use,  when  the  nasal  discharge  is  excessive,  it  is  checked  ;  when 
deficient  and  thickened,  as  in  hypertrophic  rhinitis,  its  healthy  character  is  restored  ;  and 
when  arrested,  inspissated  and  malodorous,  as  in  atrophic  rhinitis,  fluidity  is  promoted 
and  the  foul  smell  corrected.  In  cases  of  acute  rhinitis,  catarrhal  or  hypersesthetic,  in 
which  the  nostrils  are  so  blocked  that  nasal  inhalation  is  impossible,  relief,  unattainable 
otherwise,  is  afforded  by  insertion  of  a  lightly  carded  fragment  of  wool,  medicated  to  the 
extent  of  5  per  cent,  with  menthol.  The  same  method  is  serviceable  in  cases  of  atrophic 
rhinitis,  in  which  it  is  desirable  to  modify  the  over-patency  of  the  nostrils,  and  at  the  same 
time  to  stimulate  to  healthy  secretion.  Menthol,  by  means  of  wool  more  powerfully  im- 
pregnated, to  say  10  or  20  per  cent., can  be  usefullyadministered  throughan  oro-nasal  inhaler. 

Cocaine  locally  is  not  a  remedy  to  be  advised,  except  for 
exceptional  application  by  the  surgeon  for  the  relief  of  really 
acute  stenosis. 

General. — It  is  possible  in  many  instances  to  cut  short  an 
attack  at  the  first  of  an  acute  stage,  and  to  avert  the  second  by 
taking  the  mixture  in  Form.  88.  The  opium,  which  is  thus 
administered  only  in  its  stimulating  dose,  contracts  the  capillaries; 
and  the  belladonna,  while  it  appears  to  diminish  the  constipating 
effect  of  the  opium,  assists  by  its  specific  action  of  inhibiting 
glandular  secretion.  Others  recommend  quinine  in  doses  of  5  to 
10  grains,  but  it  is  a  remedy  never  prescribed  by  myself  unless 
preceded  by  a  smart  purge.  Dover's  powder  taken  at  night, 
should  symptoms  have  appeared  in  the  evening,  is  also  valuable 
with  or  without  grey  powder ;  but  my  personal  experience  is  that 
the  first  signs  of  an  acute  rhinitis  are  generally  observed  on  rising 
in  the  morning,  although  they  are  doubtless  aggravated  as  night 
approaches. 

Even  after  the  second  stage  of  coryza  has  been  reached,  the 
opium  and  belladonna  mixture  may  arrest  it ;  but  if  not,  I 
do  not  advise  further  perseverance  with  drugs.  Camphor 
internally  has  been  very  disappointing  in  my  experience, 
although  a  concentrated  spirituous  solution  sniffed  through  the 
nostrils  is  often  effective  ;  and  as  to  the  local  treatment  by  snuffs 
of  acacia,  tragacanth,  or  bismuth,  with  morphia,  I  have  never 
seen  the  least  benefit  from  their  use  (see  p.  127).  My  colleague, 
Dundas  Grant,  has  recently  suggested  a  menthol  snuff,  which  is, 
however,  of  not  quite  the  same  character  as  those  to  which  I 
object,  and  I  have  seen  good  effects  from  its  use.  It  consists  of  a 
mixture  of  menthol  and  powdered  spermaceti  in  the  proportion  of 


562 


DISEASES  OF  THE  THROAT  AND  NOSE. 


15  grains  to  the  ounce.  Ointments  of  cocaine  or  atropine,  with 
vaseHne,  are  valuable  in  the  earlier  stages,  and  also  on  cessation 
of  the  clear  hyper-secretion,  but  useless  during  the  period  of 
excessive  rhinal  flow.  Menthol  in  ointment,  or  as  a  spra}^  of  an 
oily  solution,  is  preferable  to  cocaine.  All  these  remedies  act  by 
causing  a  diminution  in  the  capillary  engorgement,  and  as  a 
consequence  in  the  amount  of  serous  exosmosis.  In  a  few 
instances  Turkish  baths  are  of  service  in  the  early  stage.  Some- 
times, however,  they  only  increase  the  symptoms  and  prolong 
the  attack.  The  explanation  of  this  untoward  effect  is  that  the 
heat  excites  capillary  distension,  while  the  transudation  by  the 
skin,  and  the  reaction  after  shampooing  and  douching,  are  insuffi- 
cient to  restore  the  normal  balance  between  the  general  vaso- 
motor control  and  the  functions  of  the  nasal  passages. 

Specific  forms  of  acute  coryza  in  relation  to  gonorrhoea  require 
special  measures  which  come  mainly  within  the  range  of  general 
surgery.  It  must  not  be  forgotten  that  acute  coryza  in  infants  is 
often  an  indication  of  a  syphilitic  dyscrasia  ;  and  this  especially 
when  the  discharge  is  purulent,  as  it  is  far  more  frequently  with 
them  than  in  the  case  of  adults.  Insanitary  surroundings  are  also 
to  be  noted  as  not  infrequently  producing  rhinitis  of  a  purulent 
form  in  adults  and  also  in  children,  especially  those  who  are  the 
subjects  of  lymphoid  hypertrophies.  The  etiology  of  the  neurotic 
disease,  hay-fever,  or  what  has  been  well  termed  by  Sd,]o\i?>  periodic 
hypercesthetic  rhinitis,  has  been  already  discussed  in  the  previous 
chapter.  Further  consideration  in  relation  to  symptoms  and 
treatment  will  be  presently  afforded. 

The  treatment  of  acute  rhinitis  complicating  the  specific  fevers — 
especially  variola,  scarlatina,  measles  and  diphtheria — is  essentially 
the  same  as  that  of  the  more  acute  forms  of  the  simple  variety,  but 
germicidal  sprays  or  douches  are  more  clearly  indicated,  and  the 
same  may  be  said  of  nasal  manifestations  in  epidemic  influenza, 
such  as  has  been  generally  manifested  during  recent  years 
throughout  Europe. 

In  children,  and  especially  in  infants,  blocking  of  the  nostrils  by 
purulent  discharge  leads  to  distressful,  and  even  dangerous,  symp- 
toms. It  is  far  more  often  associated  with  adenoid  growths  in 
the  naso-pharynx  than  is  generally  recognised,  and  in  the  newly- 
born,  especially  if  associated  with  conjunctivitis,  is  often  due  to 
the  infection  of  vaginal  discharges.  For  its  relief,  beyond  treat- 
ment of  the  exciting  cause,  it  is  necessary  to  syringe  the  nares 
two  or  three  times  daily  with  a  solution  of  borax,  of  Dobell's 
solution,  or  of  a  compound  mixture  similar  to  that  in  Form.  78. 


CROUPOUS  RHINITIS. 


563 


CROUPOUS  RHINITIS. 

Recognising  that  there  is  such  a  disease  as  diphtheritic  rhinitis 
{vide  Chapter  XVII.),  we  have  to  consider  that  there  is  also  a 
form  of  nasal  inflammation,  characterized  by  exudation  of  mem- 
brane, which,  although  probably  bacterial  in  its  nature,  holds  a 
subsidiary  position  in  pathology,  analogous  to  that  of  membranous 
croup  in  the  larynx. 

The  membrane  is  usually  found  in  the  nares  alone,  having  little 
or  no  tendency  to  extend  to  the  fauces,  pharynx,  and  larynx. 
Should  this  occur,  a  graver  form  of  specificity  may  be  presumed. 
Barclay  Baron,  however,  has  noticed  an  accompanying  keratitis 
and  iritis,  which,  however,  is  non-specific,  and  is  another 
example  of  the  intimate  sympathy  between  nasal  and  ophthalmic 
symptoms.  This  membrane  may  be  removed  without  exposing 
a  bleeding  surface.  It  has  none  of  the  characteristic  odour  of 
nasal  diphtheria,  and  although  there  maybe  some  rise  in  tempera- 
ture at  the  onset  of  an  attack,  and  the  symptoms  may  be  those  of 
acute  rhinitis,  with  its  resulting  nasal  obstruction  of  considerable 
degree,  life  is  never  in  danger,  even  though  the  vital  energies  may 
be  severely  depressed.  Anosmia  and  paralyses  as  sequelae  are 
conspicuous  by  their  absence.  Risk  of  contagion  is  most  remote. 
Cultivation  experiments  give  negative  results,  inoculation  is 
abortive.  The  neighbouring  glands  are  not  involved,  and  no 
one  has  found  the  Klebs-Loeffler  bacillus. 

McBride  has  noticed  that  there  is  a  great  tendency  to  recur- 
rence ;  this  may  possibly  be  due  to  continuance  of  insanitary 
surroundings,  which  should  be  accepted  as  constituting  an  etio- 
logical factor  of  importance. 

It  must  not  be  forgotten,  however,  that  this  condition  may  be 
simulated  by  the  use  of  strong  escharotics,  especially  those  of  the 
galvano-cautery  and  nitrate  of  silver. 

The  TREATMENT  may  be  somewhat  tedious,  mainly  because  of 
the  nasal  stenosis  and  the  difficulty  of  maintaining  the  recupera- 
tive powers. 

Local  measures  resolve  themselves  into  detaching  the  membrane 
by  a  weak  alkaline  solution,  such  as  Dobell's  solution,  or  one  of 
boric  acid,  in  the  form  of  a  coarse  spray,  followed  by  gentle 
removal  of  the  membrane  by  means  of  the  forceps,  and  finally  by 
the  application  of  iodol,  menthol,  or  weak  lactic  acid  in  the  form 
of  a  spray. 

John  Sendziak  recommends  nasal  insufflation  of  pure  aristol, 
followed  by  application  of  light  tampons  charged  with  balsam  of 
Peru  and  of  resorcine. 


564 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  nostrils  may  be  provided  with  a  respirator  of  a  hghtly- 
carded  pledget  of  menthol  wool  (5  to  10  per  cent.),  or  the  intro- 
duction of  a  hollow  nasal  bougie  lightly  wrapped  in  wool  impreg- 
nated with  menthol,  iodol,  or  aristol,  or  a  mild  sublimate  wool 
may  be  used.  Salicylate  of  quinine  and  of  iron  are  the  best 
internal  remedies,  but  many  or  all  of  these  ma}^  prove  futile  unless 
a  change  of  habitat  be  insisted  on. 

The  foregoing  remarks  may  be  taken  to  apply  also  to  what  is 
known  as  Fibrinous  or  Plastic  Rhinitis.  It  is  only  necessary  to 
add  that,  while  the  croupous  form  may  be  found  up  to  the  time  of 
middle  life,  the  plastic  form  is  mainly  confined  to  the  periods  of 
infancy  and  adolescence. 

SUBACUTE  RHINITIS. 

This  condition  is  comparatively  rare,  and,  when  present,  more 
often  calls  for  surgical  than  for  medical  treatment.  The  condition 
is  of  great  importance  in  relation  to  its  disposition,  if  not  cured, 
to  proceed  to  the  formation  of  hypertrophies ;  in  children  of  post- 
nasal adenoid  vegetations,  in  adults  of  congestions  and  thicken- 
ings of  the  covering  of  the  turbinated  bones,  especially  the  inferior 
and  the  middle,  and  of  polypi. 

Each  of  these  subjects  will  occupy  later  consideration. 

Rhinorrhcea  is  the  form  in  which  subacute  rhinitis  is  generally 
manifested.  It  is  not  necessarily  the  result  of  an  uncured  acute 
'  cold,'  or  of  a  repetition  of  acute  attacks,  though  there  is  usually 
a  history  of  catarrhal  predisposition.  Cases  are  recorded  in 
which  many  ounces  and  even  pints  of  clear  watery  fluid  have 
been  discharged  in  the  twenty-four  hours  for  periods  of  many 
months — in  one  instance,  of  nearly  two  years.  I  have  never  had 
such  an  experience,  but  have  seen  several  patients  who  suffered 
from  a  similar  condition  of  only  less  serious  grade.  There  is 
seldom  any  local  sign  beyond  congestion  of  the  membrane  and 
soreness  of  the  external  nostril ;  but  occasionally  there  is  a 
polypus  or  other  objective  cause  for  the  flow. 

The  following  are  notes  of  two  cases  that  occur  to  me  : 

Case  i  was  that  of  a  lady,  aged  38,  who  suffered  from  excessive  nasal  discharge,  which 
had  lasted  some  years,  and  greatly  prostrated  her.  I  could  discover  no  cause  for  the 
condition,  but  she  derived  great  benefit,  and  was  ultimately  cured,  by  use  of  the  opium 
and  belladonna  mixture,  with  Turkish  baths,  and  later  a  course  of  Donovan's  solution 
with  strychnia,  and  a  sojourn  at  Harrogate. 

Case  2 — Mrs.  T.,  aged  45,  was  sent  me  by  Dr.  Bastable,  April  ii,  1887,  on  account 
of  irritation  and  smarting  of  the  nostrils,  with  frequent  sneezing  and  incessant  running  of 
clear  fluid,  which  had  existed  since  last  September.  The  sense  of  smell  had  become 
diminished,  and  respiration  through  the  left  nostril  was  impossible.  She  suffered  from 
constant  hemicrania. 


NEUROTIC  OR  HYPERMSTHETIC  RHINITIS. 


565 


She  stated  that  she  had  always  been  susceptible  to  cold.  Her  skin  transpired  freely, 
but  the  slightest  draught  of  air  would  check  the  perspiration,  and  then  she  would  sneeze 
and  have  an  attack,  sometimes  of  cold  in  the  head,  sometimes  of  bronchitis.  She  had 
been  always  sensitive  to  offensive  smells,  and  had  been  rather  subject  to  sm.all,  painful 
gatherings  inside  the  nose.  All  these  conditions  had,  however,  somewhat  improved  in 
the  last  few  years. 

She  dated  her  present  condition  from  a  night  which  she  passed  in  Cologne  last 
September,  on  her  arrival  from  Wiesbaden.  It  had  been  a  very  hot  day  (97^  F.  in 
the  shade),  and  she  had  arrived  much  fatigued.  She  was  subjected  to  such  offensive 
smells  in  the  hotel  that  vomiting  and  diarrhcea  supervened,  and  she  was  ill  for  some  days. 
Since  that  time  her  nasal  symptoms,  as  above  detailed,  had  steadily  increased.  Life  was 
described  as  simply  intolerable. 

On  examination  I  found  subacute  inflammation  of  both  nostrils,  without  other  per- 
ceptible cause  for  her  symptoms.  Having  ancesthetized  the  nares  with  cocaine,  I  freely 
applied  galvano-cautery  to  both  nostrils,  and  prescribed  anterior  nasal  syringing 
(Form.  78),  and  ointment  (Form.  80  and  81  in  combination).  There  was  an  immediate 
improvement,  which  I  am  happy  to  say  has  become  permanent. 

NEUROTIC  OR  HYPERyESTHETIC  RHINITIS,  INCLUDING  HAY- 
FEVER  AND  PSEUDO-HAY-FEVER. 

Sajous  appropriately  states  that  '  Periodic  Hypersesthetic 
Rhinitis  may  be  defined  as  an  affection  characterized  by  periodical 
attacks  of  acute  rhinitis,  comphcated  sometimes  with  asthma, 
occurring  as  a  result  of  a  special  susceptibility  on  the  part  of 
certain  individuals  to  become  influenced  by  certain  substances, 
owing  to  a  deranged  state  of  the  nerve  centres.  It  manifests 
itself  only  provided  the  mucous  membrane  primarily  affected  in 
the  course  of  an  attack  is  in  a  state  of  hypersesthesia,  and  when 
the  irritating  substances  are  present  in  the  atmosphere/ 

This  condition,  otherwise  called  Summer  catarrh,  Rose-cold,  etc., 
requires  for  its  development  three  factors : 

1.  A  predisposing  neurotic  idiosyncrasy  with  debility  of  vaso- 
motor control. 

2.  A  resulting  chronic  hyperaemia  of  the  vascular  tissues  and 
hypersesthesia  of  the  nerve  endings  of  the  nasal  passages. 

3.  An  exciting  agent,  which  varies  with  the  individual  and  the 
locality.  It  may  be  the  pollen  of  a  grass,  of  a  rose,  or  of  other 
flower  ;  or  it  may  be  certain  noxious  conditions  of  the  atmosphere 
which  are  peculiar  to  certain  seasons  of  the  year  and  certain 
localities,  and  independent  of  any  vegetable  particles. 

Periodic  hypersesthetic  rhinitis,  due  to  pollen,  and  occurring 
during  the  summer,  constitutes  true  hay-fever ;  that  associated 
with  any  other  exciting  agent  is  better  distinguished  by  the  title 
of  pseudo-hay  -feve  r. 

Great  credit  is  due  to  Blackley,  of  Manchester,  for  demonstrat- 
ing, in  1873,  the  correctness  of  Elliotson's  views,  put  forth  in  1839, 


566 


DISEASES  OF  THE  THROAT  AND  NOSE. 


that  true  hay-fever  is  associated  with  the  presence  of  pollen  in  the 
inspired  air.  In  1876,  Beard,  of  New  York,  demonstrated  the 
fact  that  there  were  nwneroiLs  other  exciting  agents  besides  pollen, 
and  he  called  attention  to  the  marked  neurotic  element  in  hyper- 
sesthetic  rhinitis.  Amongst  other  biological  exciting  agents 
it  is  necessary  to  say  a  few  words  concerning  the  presence  of 
infusoria  in  the  nasal  passages  ;  Helmholtz,  in  1869,  himself  a 
sufferer  from  periodic  hyperaesthetic  rhinitis,  suggested  that  the 
disease  was  due  to  the  presence  of  vibrios  in  the  nasal  passages, 
which  exhibited  periodical  activity  during  the  hay  season.  Under 
the  term  '  vibrios,'  Helmholtz  doubtless  really  wished  to  refer  to 
certain  ciliated  animalculse,  belonging  to  the  group  Infusoria, 
which  are  sometimes  found  in  active  movement  in  the  nasal 
secretions  of  sufferers  from  hyperaesthetic  rhinitis.  On  the  few 
occasions  in  which  I  have  looked  for  these  organisms  in  hay-fever 
and  pseudo-hay-fever  patients,  I  have  not  succeeded  in  finding 
them;  and  they  were  only  present,  as  far  as  could  be  ascertained, 


Fig.  CXCV.— Nasal  Secretion  from  Case  of  Hay-Fever.    Magnified  about 


The  specimen  shows  four  ciliated  infusoria,  several  leucocytes,  a  cell  of  pavement 
epithelium,  and  debris.  At  the  foot  of  the  drawing  are  represented  a  ciliated  cell  from  the 
respiratory  epithelium,  and  one  of  Schultze's  spindle-shaped  cells  from  the  olfactory  region. 

in  the  rhinal  secretions  of  one  out  of  eleven  cases  of  hay-fever 
examined  by  Hill,  in  the  summer  of  1889.  These  organisms, 
independently  observed,  are  apparently  the  same  as  those  de- 
scribed by  Salisbury,  some  ten  years  ago,  as  present  in  an  American 
epidemic  of  influenza,  and  to  which  he  gave  the  happy  synonym 
of  infusorial  catarrh,  calling  the  organism  the  asthmatos  ciliaris. 
Elsberg  confirmed  the  observation,  and  found  similar  infusoria 
in  the  secretions  of  those  suffering  from  acute  forms  of  hyper- 
aesthetic rhinitis.  The  illustrations  here  given  (Fig.  CXCV.)  are 
from  the  pencil  of  a  medical  student  who  was  himself  the  subject 
of  the  trouble  under  consideration,  as  well  as  of  sensitive  spurs  in 
each  nostril. 

It  is  not  probable  that  the  microbe  thus  described  in  connec- 
tion with  ordinary  influenza,  or  with  hay-fever,  would  be  frequently 


600  Diame:ters. 


NEUROTIC  OR  HYPERMSTHETIC  RHINITIS. 


567 


present  in  those  suffering  from  attacks  of  the  nature  of  the  recent 
epidemic  of  Russian  influenza,  a  disease  which  gravely  affects  the 
nervous  as  well  as  the  respiratory  system ;  and  the  specific  microbe 
of  which,  so  far  as  present  investigation  shows,  is  claimed  by  some 
to  be  nearly  identical  with  the  bacillus  or  rather  diplococcus  of 
pneumonia  ;  by  others  the  microbe  is  held  to  be  of  the  nature  of 
a  flagellate  monad.  Nevertheless,  I  have  seen  cases  where,  the 
nasal  symptoms  preponderating,  ciliated  organisms  such  as  those 
here  figured  were  found  in  the  secretions  of  those  suffering  from 
the  epidemic. 

Sensitive  Areas. — Reference  has  already  been  made  in  the  pre- 
ceding chapter  to  '  sensitive  areas  '  on  the  inner  surface  of  the 
inferior  turbinated  body,  as  demonstrated  by  John  Mackenzie  and 
Hack.  It  must  now  be  conceded  that  it  is  much  too  narrow  a 
view  to  regard  this  region  as  the  only  sensitive  one.  Sajous  has 
described  three  other  hyperaesthetic  areas,  one  situated  on  the 
outer  wall  of  the  nasal  fossae  in  front  of  the  middle  turbinal,  and 
two  on  the  mucous  membrane  of  that  body — the  first  of  which  is 
near  its  anterior,  and  the  second  near  its  posterior  extremity. 
My  own  experience  would  point  to  the  fact  that  on  the  septum,  and 
especially  over  spurs  and  projections  caused  by  deflections,  there 
are  acutely  sensitive  areas,  and  that  the  situations  thereof  vary 
greatly  in  different  cases.  Some  authors  hold  that  there  are 
separate  sensitive  areas  corresponding  to  the  acts  of  lachrymation 
and  sneezing,  and  in  addition  to  an  '  asthma  zone,'  and  a  '  cough 
zone.'  It  is,  however,  contrary  to  my  experience  to  believe  that 
asthma  is  specially  connected  with  hyperaesthesia  or  morbid  lesions 
in  the  neighbourhood  of  the  terminations  of  the  nerve  of  Cotun- 
nius — the  naso-palatine  branch  of  Meckel's  ganglion.  Woakes's 
statement  that  sneezing  is  often  intimately  associated  with  hyper- 
aesthesia of  the  area  supplied  by  the  nasal  branch  of  the  ophthalmic 
is  substantially  correct,  though  sneezing  is  often  a  morbid  result 
of  hyperaesthetic  septal  spurs,  or  rather  of  contact  of  the  spur 
with  the  middle  turbinal.  In  like  manner  contact  of  the  spur 
with  the  inferior  turbinal  may  explain  some  cases  of  otherwise 
unaccountable  paroxysmal  cough.  I  have  one  such  case  now 
under  my  care. 

Too  much  trouble  and  patience  cannot  be  taken  to  ascertain 
the  existence  of  hyperaesthetic  regions  by  means  of  the  probe, 
since  they  are  often  the  cause  of  otherwise  unexplained  cases  of 
paroxysmal  cough,  vertigo,  and  other  reflex  symptoms,  the  suc- 
cessful treatment  of  which  can  only  be  attained  by  accurate 
cauterization  of  the  hyper-sensitive  sites. 


568 


DISEASES  OE  THE  THROAT  AND  NOSE. 


Cases  of  hyperaesthetic  rhinitis  occurring  in  the  winter  as  well 
as  the  summer,  and  to  which  the  term  '  pseudo-hay-fever '  has 
been  applied,  are  not  uncommon  in  my  hospital  and  private 
practice,  and  such  sufferers  are  often  engaged  in  some  dusty 
form  of  employment,  though  not  invariably  so.  I  have  seen  a 
few  cases  recently  (March,  i8go)  which  appeared  to  be  directly 
consequent  on  attacks  of  epidemic  influenza. 

The  following  case  of  hyperaesthetic  rhinitis,  in  which  the 
presence  of  pollen  proves  a  potent  excitant  in  the  summer,  and 
dust  a  less  powerful,  though  no  less  obvious,  irritating  agent  at 
other  seasons  of  the  year,  is  recorded  as  a  type  of  this  class 
of  case.  The  history  is  simply  condensed  from  the  patient's 
graphically  written  statement. 

W.  H.  H.,  captain,  R.N.,  ret.  43,  came  under  my  care  in  May,  1888,  stating  that 
he  had  suffered  from  hay-fever  since  two  years  of  age,  certainly  as  long  as  he  can 
remember  ;  entered  the  navy  in  June,  1859  ;  suffered  only  slightly  during  a  summer 
spent  in  Nova  Scotia,  although  he  assisted  to  '  make  hay  '  more  than  once  ;  whilst 
serving  in  Channel  Squadron,  from  1864  to  1866,  noticed  that  the  '  hay- fever  was 
modified  by  residence  on  board  and  avoidance  of  the  shore.'  When  stationed  at  Ports- 
mouth he  later  observed  that  he  suffered  severely  on  shore  ;  the  symptoms  disappeared, 
however,  twenty-four  hours  after  leaving  in  a  troopship  for  the  Mediterranean,  but  on 
reaching  the  Gut  of  Gibraltar,  where  a  strong  east  wind  was  blowing  off  land,  he  had  a 
severe  relapse.  During  a  voyage  round  the  world,  in  1869  and  1870,  though  never  quite 
free  from  catarrh,  had  no  very  inconvenient  symptoms  ;  even  in  the  tropics,  however, 
the  nasal  mucous  membrane  was  always  hypersesthetic,  and  especially  so  during  the 
months  of  June  and  July.  Whenever  he  spent  a  summer  in  England  he  got  asthma  and 
had  to  go  to  the  seaside.  During  service  on  the  Australian  station  he  always  had  hay- 
fever  symptoms  in  Melbourne  (a  very  dusty  town  in  those  days),  but  suffered  scarcely  at 
all  in  Tasmania.  The  attacks  in  the  southern  hemisphere  were  of  a  different  and  milder 
character  to  those  experienced  in  England  and  France,  asthma  never  being  experienced 
south  of  the  line,  but  only  (modified)  coryza.  '  An  ordinary  attack  begins  with  violent 
sneezing  fits,  great  irritation  and  secretion  from  the  eyes,  very  copious  discharges  from 
the  nares,  and  irritation  of  the  palate ;  as  the  inflammation  extends  to  the  throat,  asthma 
and  a  most  distressing  cough  supervenes,  which  remains  after  the  other  symptoms  have 
disappeared. ' 

On  examination,  this  patient  had  well-marked  evidences  of  hyperajmia  and  hyper- 
trophy of  the  inferior  and  middle  turbinated  bodies,  but  without  any  marked  septal 
deviation  or  outgrowth.  Application  of  the  probe  about  half-way  back  in  the  inferior 
meatus  produced  violent  sneezing  and  distress.  The  soft  palate  was  paretic,  and  the 
uvula  thickened  and  relaxed,  and  there  also  existed  varix  of  the  vessels  of  the  base  of  the 
tongue,  and  hypertrophy  of  the  lingual  tonsil.  Only  the  slightest  evidences  of  pulmonary 
emphysema  were  to  be  detected,  but  the  patient  stated  that  when  under  the  influence  of 
an  acute  attack,  his  chest  trouble  was  considerably  aggravated.  Galvano-caustic  treat- 
ment to  the  various  implicated  regions  with  internal  administration  of  phosphide  of  zinc, 
arsenic,  and  nux  vomica  ultimately  resulted  in  a  successful  issue,  the  patient  writing  in 
December,  1888  :  '  I  am,  and  have  been,  very  well.  I  was  in  Wales  from  2nd  August  to 
6th  September,  during  the  whole  time  hay  was  making,  and  I  certainly  suffered  less  than 
I  have  ever  done  before  in  England.' 


For  the  correct  interpretation  of  the  various  symptoms,  and  a 


NEUROTIC  OK  HYPERyESTHETIC  RHINEFIS.  569 


proper  comprehension  of  the  indications  for  scientific  treatment, 
it  cannot  be  too  strongly  urged  that  the  predisposing  factors  are 
of  overwhelmingly  greater  importance  than  the  exciting.  This  is 
so,  whether  the  local  condition  be  that  of  the  acute  coryza  and 
temporary  nasal  stenosis  of  hay-fever,  or  the  asthma  and  other 
respiratory  symptoms  sometimes  associated  with  them,  and  some- 
times separately  manifested.  The  nature  of  the  predisponents 
has  been  indicated  in  the  previous  chapter.  It  remains  to  briefly 
enumerate  the  chief  symptoms  of  the  malady,  and  to  indicate  the 
lines  for  rational  therapy. 

The  SYMPTOMS  are  in  the  first  instance  those  of  acute  catarrh; 
but  they  occur  more  suddenly,  and  are  manifested  much  more 
severely ;  the  sneezing,  coryza,  nasal  stenosis,  headache,  and 
debility  all  being  more  acutely  distressing  than  is  observed  in 
non-specific  rhinitis.  Added  to  these  manifestations,  there  is 
excessive  lachrymation,  with  conjunctivitis  and  effusion  into  the 
eyelids.  Patients  frequently  complain  of  sore  throat  and  of  great 
irritation,  sometimes  of  the  nature  of  an  incontroUable  itching  of 
the  palate.  Where  the  veins  are  engorged  there  is  pharyngeal 
tenesimts,  a  condition  in  w^hich  all  the  symptoms  of  rectal  tenesmus 
are  accurately  simulated.  Pyrexia  is  of  varying  degree,  and  as  a 
rule  is  less  than  in  an  ordinary  acute  cold  in  the  head. 

Beyond  these  catarrhal  symptoms,  and  sometimes  independent 
of  them,  or  at  least  of  far  more  distressing  importance,  occurs  an 
asthma  of  acute  and  quite  temporary  character.  This  symptom 
differs  from  the  same  respiratory  malady  uncomplicated  by  the 
direct  irritation  of  season,  in  that  it  is  manifested  in  the  day  quite 
as  frequently  and  as  intensely  as  at  night.  It  passes  away  with- 
out leaving  any  impress  on  the  lung  tissue,  and  does  not  recur 
until  the  return  of  the  season  favourable  to  an  attack. 

The  TREATMENT  of  hay-fever  until  recently  has  been  not  only 
most  irrational,  but  (if  one  may  use  such  a  term)  cowardly. 
Instead  of  attacking  the  predisposing  idiosyncrasy,  or  the  local 
hypersemia,  the  former  has  been  accepted  as  inevitable,  and  the 
latter  ignored ;  while  as  to  the  exciting  irritant  agent,  it  has  been 
simply  shut  out.  Confinement  to  the  house,  change  of  residence, 
plugging  the  nostrils  with  tampons  of  wool,  the  wearing  of 
goggles  and  double-gauze  veils,  are  measures  of  but  little  value  in 
arresting  an  attack,  and  in  no  sense  preventive  of  a  recurrence. 
Nor  are  snuffs,  whether  containing  morphia  (as  do  those  known 
as  Ferrier's),  or  of  boracic  or  salicylic  acid,  or  with  either  of 
these  plus  capsicum  (as  advised  by  Mortimer  Granville),  any  more 
useful  than  might  be  expected  in  consideration  of  the  unphysio- 


570 


DISEASES  OF  THE  THROAT  AND  NOSE. 


logical  character  of  the  indications  advanced  by  their  advocates. 
My  view^s  on  these  questions  are  the  result  of  a  lengthened 
experience.  They  were  set  forth  more  fully  in  a  paper  on  the 
treatment  of  hay-fever,  which  was  published  in  the  British  Medical 
Journal,  June  21,  1884. 

The  neurotic  state,  once  recognised,  is  to  be  attacked  on  general 
principles  by  nerve  tonics,  electricity,  general  douches,  massage, 
and  the  like.  And  these  lines  may  be  pursued  with  advantage  in 
the  intervals  of  the  seasons  in  which  the  attacks  appear.  As  a 
nerve  tonic  I  am  in  the  habit  of  prescribing  a  triturate  composed 
of  jVth  grain  of  phosphide  of  zinc,  and  Jth  grain  of  extract  of  nux 
vomica,  and  I  have  also  found  service  from  another  combination 
much  lauded  by  Bosworth,  namely,  phosphide  of  zinc,  arsenious 
acid,  and  belladonna.  On  occurrence  of  an  attack  remedial 
measures  are  to  be  divided  into  (i)  palliative,  and  (2)  radical. 

Palliative  internal  measures  may  be  represented  by  the  opium 
and  belladonna  mixture,  or  by  large  doses  of  quinine  with  or 
without  hydrobromic  acid,  preceded  by  a  purge. 

Palliative  local  treatment  includes  the  inunction  of  the  nostrils 
and  eyelids  with  ointments  of  vaseline  with  atropine.  The  use 
of  the  menthol  inhaler  or  of  an  oro-nasal  inhaler  with  the  inhalant 
in  Form.  41,  or  inhalations  of  the  vapour  of  chloride  of  ammonium, 
in  combination  with  various  medicaments,  such  as  ozonic  ether, 
oil  of  eucalyptus  or  pine  in  alcohol,  menthol,  camphor,  chloro- 
form, or  aldehyde.  Anti-catarrhal  smelling  salts  (Form.  116),  the 
action  of  which  is  quite  different  from  that  of  snuffs,  are  often 
of  great  value  in  hay-fever.  They  probably  act  by  stimulating 
the  capillaries  to  contraction.  The  comparatively  new  remedy, 
cocaine,  has  more  than  answered  expectations  in  giving  relief 
to  the  symptoms  of  hay-fever,  and  since  its  physiological  action 
is  to  contract  the  capillaries  of  the  lower  turbinated  bodies,  its 
success  has  confirmed  the  views  previously  expressed,  that  the 
main  predisposing  factor  of  local  importance  was  a  general  or 
local  area  of  excessive  vascularity  in  some  portion  of  the  nostrils. 
Cocaine  may  be  administered  in  ointment,  as  a  spray,  or  by  intro- 
duction into  the  nostrils  of  pledgets  of  wool  soaked  in  a  solution. 
The  dangers  of  persistent  cocainism  already  insisted  on  (p.  147), 
are  to  be  borne  in  mind  and  avoided. 

Radical  local  treatment  consists  in  destruction  of  any  hyper- 
plasias or  polypi  in  the  nostrils,  or  in  reduction  of  its  vascular 
supply  by  the  careful  application  to  any  hypersemic  area  of  galvano- 
cautery,  or  of  some  other  caustic  agent,  of  which  may  be  named 
in  their  order  of  efficiency,  chromic  acid,  fuming  nitric  acid,  and 


CHRONIC  HYPERTROPHIC  RHINITIS. 


571 


glacial  acetic  acid.  Preliminary  to  any  of  these  applications,  the 
membrane  is  to  be  ansesthetized  by  cocaine  and  then  dried. 

It  is  hardly  necessary  to  mention  that  any  other  local  cause  of 
irritation,  as  a  septal  spur  or  deformity,  a  relaxed  uvula,  enlarged 
veins,  or  granulations  at  the  back  of  the  pharynx,  should  be  looked 
for,  and  if  present  should  be  effectively  removed,  according  to  the 
lines  laid  down  in  the  appropriate  sections.  Although  I  usually 
recommend  adoption  of  these  slight  operative  procedures  either 
before  an  acute  onset  or  after  its  subsidence,  I  have  occasionally 
pursued  them  at  the  request  of  a  patient  on  supervention  of  an 
attack.  I  have  never  seen  any  harm  result  therefrom,  but  on  the 
contrary  have  generally  succeeded  in  arresting  the  symptoms. 

CHRONIC  HYPERTROPHIC  RHINITIS. 

I  have  already  in  the  previous  chapter  dwelt  at  some  length  on 
the  etiology  of  simple  hypertrophic  rhinitis.  I  am  in  agreement 
with  John  Mackenzie  in  believing  that  it  is  the  result  of  the 
frequently  recurring  erections  associated  with  repeated  acute  and 
sub-acute  attacks  of  catarrh.  Amongst  other  occasional  con- 
comitant factors  in  the  induction  of  hypertrophy  of  the  nasal 
mucous  membrane,  may  be  mentioned,  however,  climatic  con- 
ditions, living  or  working  in  dust-laden  or  other  deleterious 
atmospheres  and  insanitary  surroundings,  tobacco  smoking,  and 
various  constitutional  states,  including  the  (?)  catarrhal,  gouty, 
rheumatic,  and  scrofulous.  The  lesions  may  date  from  some 
specific  fever.  Bosworth  recognises  none  of  the  above  as  factors 
of  importance,  but  teaches  that  genuine  hypertrophy  is  nearly 
always  subsequent  to  anterior  stenosis,  due  either  to  septal  out- 
growths and  deformities — the  commoner  cause — or  to  collapse 
of  the  alae  and  consequent  narrowing  of  the  anterior  entrance  to 
the  nares;  and  he  insists  that  repeated  erection  and  consequent 
hypertrophy  brought  about  through  the  frequently  repeated  act  of 
hawking  of  thick  phlegm  from  the  posterior  nares  and  naso- 
pharynx into  the  fauces,  diminishes  atmospheric  pressure  in  the 
nasal  cavities  when  there  is  anterior  stenosis,  and  induces  over- 
growth of  the  mucosa.  From  statistics  taken  in  the  last  nine 
months  of  the  incompleted  current  year,  of  1,180  cases  of  nasal 
disease  treated  at  the  Central  Throat  and  Ear  Hospital,  547 
patients  are  recorded  as  suffering  from  hypertrophic  rhinitis,  and 
of  these  238  were  the  subject  of  very  obvious  deviations  of  the 
septum.  While,  therefore,  I  am  quite  prepared  to  admit  that 
hypertrophic  conditions  of  the  nasal  mucosa  are  in  something 


572  DISEASES  OF  THE  THROAT  AND  NOSE. 

like  fifty  per  cent,  of  the  number  complicated  by  spurs  and  devia- 
tions of  the  septum,  and  while  I  am  fully  alive  to  the  fact  that 
part  of  the  successful  treatment  of  hypertrophic  obstruction  con- 
sists in  remedying  any  marked  septal  deviation  by  operative 
measures,  I  am  unable  to  accept  the  view  that  spurs  are  invari- 
ably present,  or  that  they  are  an  actual  cause  of  hypertrophy  with- 
out more  cogent  reasons,  for  in  the  case  so  complicated  the 
hypertrophy  of  the  mucosa  is  very  frequently  greatest  in  the 
nostril  which  is  least  encroached  on  by  the  septal  spur — that  is,  on 
the  side  with  least  anterior  stenosis.  It  is  still  more  difficult  to 
prove  that  very  slight  deflections,  or  very  small  non-sensitive  spurs 
have  a  causal  relation  to  the  affection  under  consideration.  On 
the  other  hand,  Bosworth's  suction  theory  cannot  be  lightly  dis- 
missed, even  though  we  may  reject  the  paramount  causative  im- 
portance of  spurs,  which,  after  all,  are  by  no  means  infrequently 
present  in  non-hypertrophic  conditions.  There  is  no  gainsaying 
the  fact  that  the  alae  nasi  are  very  frequently  collapsed  and 
dimpled,  with  paresis  of  the  dilator  muscles.  Anyone  who  has 
had  much  to  do  with  the  treatment  of  nasal  obstruction  will 
admit  that  this  collapse  is  often  an  obstinate  and  troublesome 
complication  w^hen  all  hypertrophies  and  growths  have  been 
successfully  reduced;  and  in  reference  to  this,  Roughton  has 
correctly  pointed  out  that  there  is  often  present  in  such  cases 
a  constricting  band  in  close  proximity  to  the  septum,  exactly 
opposite  the  dimple,  on  the  mucous  wall  of  the  ala,  at  a  spot 
cutting  off  the  vestibule  from  the  choanse.  The  approximation 
of  this  band  to  the  septum  disappears  on  the  introduction  of  the 
speculum,  and  is  doubtless  on  this  account  frequently  overlooked. 
I  shall  allude  later  to  my  methods  of  treating  this  troublesome 
alar  collapse. 

My  colleague,  Mr.  Wyatt  Wingrave,  has  for  some  time  past 
utilized  the  wealth  of  pathological  material  provided  at  our 
hospital,  and  as  a  result  of  much  patient  investigation  has  been 
enabled  to  bring  into  harmony  a  number  of  apparently  opposite 
views  of  different  observers,  by  a  subdivision  of  the  forms  of 
hypertrophic  rhinitis  ;  these  may  be  enumerated  both  in  order  of 
their  importance  and  of  their  occurrence  as  four  different  varieties? 
namely:  (i)  the  Vascular  or  Cavernous,  (2)  the  Mucoid,  (3)  the 
Lymphoid,  (4)  the  Glandular.  Each  of  these  forms  may  either 
be  paramount,  or  may,  under  certain  circumstances,  be  separately 
evidenced.  But  it  is  more  often  the  rule  to  find,  at  least  in  the 
earlier  stages,  a  combination  of  more  or  less  of  the  different  forms. 
For,  given  a  knowledge  of  the  normal  appearance  of  these  regions. 


CHRONIC  HYPERTROPHIC  RHINITIS. 


573 


the  naked  eye  alone,  by  anterior  rhinoscopy,  may  in  a  large 
measure  enable  us  to  foretell  them  with  some  degree  of  pre- 
cision. 

Thus,  for  example,  an  enlargement  of  the  anterior  portion  of 
the  inferior  turbinal,  or  the  greater  part  of  the  middle  turbinal, 
will  more  likely  be  associated  with  the  mucoid,  lymphoid,  and 
glandular  forms,  than  would  be  the  case  in  the  posterior  and 
inferior  portion  of  the  inferior  turbinal  body,  which  is  the  seat  of 
the  cavernous  changes.  Overgrowth  of  the  mucous  covering  of 
the  septum  is  generally  glandular,  and  this  is  to  be  distinguished 
from  chondrial  and  perichondrial  overgrowths. 

Reverting  to  the  cavernous  variety,  careful  histological  investiga- 
tion has  distinctly  shown  that  the  changes  in  the  postero-inferior 
end  of  the  inferior  turbinal  constitute  a  true  varix,  and  it  is  prob- 
able that  clinical  experience  will  prove  that  these  cases  are 
associated  with  some  form  of  nasal  stenosis.  Concurrently  with 
this  turbinal  varix,  we  often  find  varix  of  the  pharyngo-glossal 
region,  and  hypertrophy  of  the  lingual  tonsil,  with  other  evidences 
of  either  hereditary  or  degenerative  varix.  And  this  condition 
accounts  not  only  for  excessive  nasal  secretion,  but  for  some  forms 
of  epistaxis,  and  for  those  symptoms  known  as  '  reflex,'  many  of 
which  have  been  grouped  by  myself,  when  occurring  in  the  pharynx 
and  larynx,  under  the  generic  term  of  '  regional  tenesmus.'  The 
mucoid  forms  occur  in  those  regions  to  which  we  most  often  look 
for  polypi,  and  are  the  result  of  successive  submucous  oedemas. 

The  glandular  forms  would  appear,  according  to  the  observa- 
tions of  Wingrave,  to  be  the  least  frequent,  and  to  be  associated 
with  the  hypergesthetic  or  periodic  forms  of  rhinitis. 

The  SYMPTOMS  of  hypertrophic  rhinitis — whatever  the  variety — 
are  those  of  nasal  obstruction  as  already  enumerated,  and  are  both 
rhinal  and  remote.  Clinically  I  am  in  the  habit  of  dividing  the 
symptoms  into  those  which  are  commonly  and  those  which  are 
only  occasionally  or  exceptionally  present. 

Amongst  the  common  characteristic  evidences  are  a  feeling  of 
stuffiness  and  inability  to  breathe  freely  through  the  nostrils;  this 
is  accompanied  by  the  dry  throat  in  the  morning  on  waking, 
and  the  typical  physiognomy  of  the  mouth-breather  ;  the  voice 
is  either  muffled,  toneless  and  hoarse,  or  exhibits  a  so-called 
nasal  twang.  There  is  nearly  always  in  fully  established  cases 
some  morbid  condition  of  the  contiguous  air-passages,  of  which 
Eustachian  obstruction,  chronic  pharyngitis,  both  of  the  hyper- 
trophic or  atrophic  form,  pharyngeal  and  lingual  varix,  elongated 
uvula,  paretic  velum,  and  chronic  laryngitis  are  the  most  frequent. 


574 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Of  the  non-constant  or  occasional  symptoms,  impairment  of  the 
functions  of  hearing  and  of  smell,  and  of  the  appreciation  of 
flavours,  are  amongst  the  most  marked.  Headache,  lassitude, 
aprosexias,  and  epistaxis,  are  more  or  less  frequent,  though  not 
always  referred  to  by  the  patient.  Prominent  reflex  neurotic 
symptoms,  in  spite  of  the  amount  that  has  been  written  of  them, 
are  not  of  severe  grade  as  results  of  ordinary  hypertrophic  rhinitis, 
although  they  are  sufficiently  common.  Their  connection  with 
hypersesthetic  rhinitis  has  already  been  insisted  on. 

Much  difference  of  opinion  appears  to  exist  as  regards  the 
secretions.  Thus  whilst  Sajous  holds  that  they  are  increased, 
Bosworth  teaches  that  they  are  diminished.  It  can  with  con- 
fidence, however,  be  asserted  that  in  hypertrophic  catarrh  the 
rhinal  secretions  are  abnormal  and  modified ;  in  many  instances, 
but  especially  in  the  early  stages,  the  fluids  poured  out  are 
apparently  increased  in  amount,  later  the  watery  constituents 
are  diminished,  and  hence  the  nasal  passages  become  blocked 
with  thick  mucus  which  the  impaired  ciliary  action  is  incapable 
of  speedily  removing.  It  must  be  remembered  that  if  there 
is  much  anterior  stenosis,  normal  nasal  respiration,  involving 
the  duty  of  saturating  the  inspired  air  with  moisture,  is  in 
abeyance,  so  that  although  only  the  normal  quantity  of  watery- 
fluid  is  actually  poured  out,  there  is  excess  in  the  choanae  ; 
later,  as  hyperplasia  in  the  deeper  layers  of  the  thickened  mucous 
membrane  proceeds,  transudation  of  the  watery  and  serous 
fluid  diminishes,  whilst  the  mucous  glands  are,  to  say  the  least, 
apparently  not  less  active  than  in  health.  This  relative  increase 
in  the  mucin  and  solid  constituents  of  the  secretion  gives  rise 
to  the  accumulation  in  the  accessory  sinuses  and  choanae,  and 
together  with  collapse  of  the  alse  explains  the  inability  to  satis- 
factorily blow  and  clear  the  nose,  which  is  so  often  complained  of; 
while  the  presence  of  mucus  and  muco-purulent  accumulations  at 
the  back  and  sides  of  the  pharynx,  which  can  be  accounted  for  in 
the  same  way,  gives  rise  to  characteristic  hawking  and  hemming. 
This  condition,  known  as  post-nasal  catarrh,  may  or  may  not  be 
associated  with  morbid  catarrhal  changes  in  the  naso-pharyngeal 
cavity.  As  regards  the  character  of  the  secretions  in  hypertrophy, 
they  always  contain  leucocytes,  and  on  account  of  the  stagnation  in 
the  nasal  cavities  the  mucus  sometimes  assumes  a  muco-purulent, 
a  blood-stained,  and  more  rarely  a  foetid  condition.  Bosworth 
believes  that  foetor  of  the  breath  in  hypertrophic  catarrh  is  always 
due  to  bad  teeth,  foul  tongue,  or  some  such  extra-nasal  cause,  but 
in  my  experience  foetor,  usually  quite  distinct  in  character  from 


CHRONIC  HYPERTROPHIC  RHINITIS. 


575 


that  occurring  in  atrophic  rhinitis,  occasionally  results,  as  is  also 
more  rarely  the  case  in  polypus,  from  long-continued  retention  of 
the  secretions  in  the  fossae,  and  especially  in  the  antrum  and  other 
accessory  cavities. 

Physical  Examination. — On  the  outside,  the  nose  often  appears 
thickened  above,  especially  in  the  upper  two-thirds ;  but  this  is 
frequently  more  apparent  than  real,  on  account  of  collapse  of  the 
alae  below,  and  this  thickening  is  usually  much  more  marked  in 
the  case  of  polypi  than  of  hypertrophic  rhinitis.  On  raising  the 
tip  of  the  nose  with  the  thumb  it  is  possible  with  a  good  reflected 
light  to  explore  the  vestibule,  and  ascertain  whether  the  pro- 
minent constricting  band  forming  the  outer  pillar  of  the  slit 
between  the  vestibule  and  choanae  is  so  approximated  to  the 
septum  during  ordinary  respiration  as  to  be  in  itself  a  factor  in 
stenosis.  On  dilating  with  a  speculum  this  sHt  is  widened,  and 
the  nasal  passages  come  more  or  less  into  view,  according  to  the 
degree  and  site  of  the  hypertrophy.  If  much  secretion  obstructs 
the  view,  a  nasal  spray  or  douche  followed  by  gentle  use  of  the 
pocket-handkerchief  will  be  necessary. 

The  areas  containing  cavernous  tissue  are  usually  most  and 
first  affected.  The  thickening  of  the  inferior  turbinated  body  may 
be  more  marked  at  one  or  other  extremity,  or,  as  is  usually  the 
case,  the  whole  of  the  body,  including  the  underlying  bone,  is 
enlarged  in  its  entire  length,  the  prominence  being  most  marked 
at  its  anterior  end,  where  it  not  infrequently  touches  the  septum, 
causing  anterior  stenosis.  This  swelling  is  usually  red  and 
globular,  but  may  be  moriform,  and  is  quite  unlike  a  polypus, 
from  which,  moreover,  it  can  easily  be  further  differentiated  by 
determining  its  attachment  with  a  probe.  It  only  partly  subsides 
under  cocaine,  but  sufficiently  to  enable  one  to  explore  the  middle 
turbinated  body  and  meatus  and  the  upper  part  of  the  septum. 
This  feeble  response  to  cocaine  enables  one  to  differentiate 
cavernous  hypertrophy  from  ordinary  catarrhal  swellings.  Hyper- 
trophy of  the  middle  turbinated  body  is  usually  most  marked  at 
its  lower  edge.  It  differs  in  appearance  from  thickening  of  the 
mucosa  of  the  septum  and  inferior  turbinal,  in  that  it  is  whitish, 
gelatinous,  and  translucent  like  a  polypus,  and  hence  often  termed 
polypoid. 

A  thickening  of  the  septal  mucosa  and  the  presence  of  osteo- 
cartilaginous spurs  and  deviations  can  readily  be  made  out  by 
anterior  rhinoscopy  and  probing.  The  latter  do  not,  of  course, 
respond  to  cocaine  so  far  as  bulk  is  concerned,  though  the  colour 
may  be  lessened  by  capillary  contraction. 


576 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Posterior  rhinoscopy  usually  reveals  some  swelling  of  the 
hinder  extremities  of  the  middle  and  inferior  turbinals,  and 
occasionally  of  the  tubercle  of  the  septum.  The  hypertrophy, 
however,  is  almost  invariably  most  prominent  at  the  hinder 
extremity  of  the  inferior  turbinated  body.  These  swellings  are 
of  two  kinds,  viz.,  the  red  and  fleshy-looking,  and  the  whitish, 
gelatinous,  or  polypoid.  I  think  the  latter  are  more  frequent. 
They  vary  much  in  size,  from  that  of  a  pea  to  that  of  a  small 
walnut,  and  may  entirely  block  the  naso-pharynx.  Most  cases 
come  under  notice  when  the  growth  is  about  the  size  of  a  hazel- 
nut, as  they  then  begin  to  affect  the  hearing.  The  surface  may 
be  likened  to  that  of  a  mulberry  in  form  and  sometimes  in  colour; 
but  reddish  and  also  translucent  globular  swellings  are  by  no 
means  rare. 

Prognosis. — The  evil  consequences  of  hypertrophic  rhinitis  are 
those  of  nasal  obstruction,  detailed  in  the  previous  chapter.  The 
prognosis  is  usually  good  as  to  reduction  of  the  stenosis  ;  but  as 
regards  the  frequently  concomitant  symptom  of  deafness,  much 
will  depend  on  the  length  of  duration  of  the  morbid  conditions 
of  the  middle  ear. 

Treatment. — Palliative  medication,  in  the  shape  of  douches, 
sprays,  and  medicated  bougies,  are  of  service  in  those  conditions 
of  subacute  catarrhal  erectile  swelling  which  follow  acute  attacks, 
and  represent  initial  stages  of  hypertrophy  ;  but  when  hvper- 
trophic  overgrowth  of  the  layers  of  the  mucosa  is  fully  established 
it  is  mere  waste  of  time  to  dally  with  such  remedies ;  only  surgical 
measures  are  likely  to  do  any  real  good  in  relieving  the  obstruc- 
tion. In  the  simpler  cases  of  turbinated  overgrowth,  uncompli- 
cated by  septal  deformities  and  mulberry-shaped  excrescences, 
the  reduction  of  tissue  and  relief  of  obstruction  is  best  effected 
by  some  destructive  cauterizing  agent.  The  cautery  should,  if 
scientifically  employed,  attain  two  ends,  viz.,  {a)  the  reduction  of 
the  superficial  layers  of  the  mucosa  by  the  formation  of  a  slough, 
and  (6)  the  shrinking  of  the  underlying  vascular  tissues  by  the 
formation  of  inflammatory  adhesions  to  the  periosteum. 

In  my  own  practice  for  this  purpose,  I  employ  the  galvano- 
cautery.  When  there  is  a  large  hypertrophied  inferior  turbinated 
body,  I  am  in  the  habit  at  the  first  sitting  (after  cocainizing  the 
nasal  cavities)  of  plunging  a  long  and  slender  cautery-point  into 
the  cavernous  tissues  in  a  direction  close  to,  and  as  near  as  possible 
parallel  with,  the  inferior  border  of  the  bone.  In  moderate  cases 
one  or  two  such  procedures  may  suffice  to  secure  the  requisite 
reduction  of  the  inferior  turbinated  swelling  ;  but  when  the  con- 


CHRONIC  HYPERTROPHIC  RHINITIS. 


577 


dition  is  very  marked,  little  reducible  under  cocaine,  and  of  long 
standing,  it  is  necessary  to  make  linear  superficial  cauterizations 
as  well,  especially  along  the  inner  and  lower  sides  of  the  body. 
The  anterior  third  of  the  inferior  turbinal  may  be  burnt  at  one 
sitting,  the  middle  third  a  week  after,  and  the  operations,  if  more 
are  necessary,  repeated  at  similar  intervals. 

I  rarely  apply  the  electro-cautery  to  the  posterior  third  of  the 
turbinals.  Hypertrophies  in  this  site  are  more  easily  and,  on 
account  of  the  proximity  of  the  Eustachian  tube,  much  more 
safely  reduced  by  means  of  a  snare  passed  through  the  inferior 
meatus  and  adjusted  to  the  excrescence  by  aid  of  a  finger  in  the 
naso-pharynx.  Large  globular  and  also  moriform  enlargements 
of  the  anterior  extremity  of  the  inferior  turbinated  bodies  are  best 
removed  by  transfixion  with  a  needle  and  then  snared.  In  some 
cases  the  entire  removal  of  the  posterior  overgrowth  by  the 
'  spoke  shave '  of  my  colleague,  Carmalt  Jones,  has  yielded  excel- 
lent results,  though  it  is  important  to  note  that  it  is  sometimes 
attended  by  rather  brisk  haemorrhage.  Hypertrophies 
of  the  middle  turbinated  body  are  most  safely  snared, 
being  held  in  position  for  adjusting  the  loop  by  means 
of  small  hooks  or  fine  forceps.  If  they  are  not  satis- 
factorily reduced  by  these  means  the  galvano-cautery 
may  be  employed ;  but  I  would  warn  younger  members 
of  the  profession  that  it  must  be  used  at  the  upper  part 
of  the  nasal  cavities  with  considerable  caution.  ^ 

Many  specialists,  including  some  of  my  own  col- 
leagues, prefer  to  use  chromic  acid  instead  of  the 
galvano-cautery  in  cases  of  inferior  and  middle  turbi- 
nated hypertrophy,  and  I  have  become  in  recent  years 
a  convert  to  its  more  extended  use.  It  must  be  borne 
in  mind,  however,  that  acid  cauteries,  even  if  the 
healthy  mucosa  is  protected  by  intra-nasal  guards, 
require  to  be  applied  with  care  and  discrimination. 


My  method  of  applying  chromic  acid  is  as  follows  :  First,  a  cotton-wool 
pledget  soaked  in  a  solution  of  cocaine  hydrochlorate,  about  15  per  cent., 
is  introduced  into  the  nostril  to  be  cauterized,  and  in  the  direction  of  the 
tissues  to  be  attacked,  viz.,  along  the  inferior  or  middle  meatus.  Then  the 
applicator,  which  consists  of  a  piece  of  copper  flattened  at  one  end  and 
turned  as  a  screw  at  the  other,  and  with  a  shoulder,  as  shown  in  Fig.  CXCV./'^ 
is  charged  with  chromic  acid.  This  acid  should  be  kept  in  a  state  of 
deliquescence  and  in  very  small  quantity  in  a  stoppered  bottle,  so  that  on  ^  ^ 

tilting  the  bottle  the  applicator  takes  up  the  acid  on  only  one  side.    Then  ^ 
any  excess  of  the  acid  at  the  edges,  or  on  the  opposite  side  of  the  copper 
rod,  is  to  be  wiped  off,  and  the  acid  fused  on  to  the  applicator  by  holding  ^ 
it  over  a  gas  or  spirit  flame.  ^ 

37  ^ 


578 


DISEASES  OF  THE  THROAT  AND  NOSE. 


The  screw  end  of  the  instrument  is  then  armed  with  absorbent  cotton,  and  by  this 
time,  the  nostrils  having  probably  become  sufficiently  anaesthetized,  the  cocaine  pledget 
is  removed,  and  the  tissues  dried  by  the  wool-covered  end  of  the  applicator. 

The  foregoing  precautions  are  necessary  to  prevent  too  great  diffusion  of  the  acid,  as  is 
the  case  if  it  is  applied  wet,  or  as  an  undeliquescent  crystal,  or  unless  the  parts  are  pre- 
viously deprived  of  any  superfluous  moisture.  To  actually  apply  the  chromic  acid,  it  is 
important  to  touch  only  the  tissues  to  be  cauterized,  and  in  the  case  of  the  inferior 
turbinal  body,  to  carry  the  instrument  far  back,  and  all  round  the  body,  and  not,  as  is 
so  often  done,  to  make  but  one  small  patch. 

Immediately  on  withdrawing  the  cauterizer,  a  coarse  spray  (Fig.  LXXIII.)  con- 
taining Dobell's  solution  is  to  be  employed,  in  order  to  neutralize  any  excess  of  the 
acid,  and  to  ensure  against  systemic  poisoning,  an  accident  which  has  more  than  once 
been  reported.  Lastly,  when  the  nose  has  been  *  mopped,'  not  '  blown  '  with  the  hand- 
kerchief, a  mild  spray  of  menthol  may  be  used. 

Thickening  of  the  mucous  membrane  of  the  septum  can  be  some- 
what reduced  by  cauterization,  but  this  remedy  is  seldom  required. 
On  the  other  hand,  the  rectification  by  saws,  trephines,  and  other 
surgical  means  of  osseous  and  cartilaginous  septal  deformities 
and  spurs,  which  are  so  frequently  present  and  complicate  obstruc- 
tive hypertrophic  rhinitis,  is  a  measure  to  which  I  attach  the  very 
greatest  importance.  The  treatment  of  these  complications  is 
fully  given  in  a  succeeding  section.  Solid  bougies  are  not  used  so 
frequently  by  me  as  by  some  surgeons,  except  after  operations  on 
the  septum,  in  which  cases  I  prefer  the  nasal  vulcanite  tubes  sug- 
gested by  Dundas  Grant.  When  the  treatment  by  cautery  and 
the  rectification  of  septal  deformities  fails  to  properly  relieve  the 
obstruction,  attempts  at  gradual  dilatation  by  vulcanite  bougies 
have  been  in  my  experience  more  or  less  disappointing ;  but  quite 
recently  I  have  had  most  encouraging  results  from  the  use  of 
gelatine  bougies  formed  on  a  rigid  nucleus  of  wire  and  medi- 
cated with  iodol,  chloride  of  zinc,  etc.  I  have  been  led  to 
employ  them  from  the  reports  of  the  success  Mr.  Hurry  Fenwick 
has  had  by  similar  treatment  of  urethral  stricture.  In  some  cases 
of  hypertrophic  rhinitis,  as  well  as  in  many  of  polypi,  collapse  of 
the  nostrils  remains  as  a  more  or  less  permanent  cause  of  trouble 
after  the  original  malady  has  been  removed.  For  relief  of  this  con- 
dition stimulant  smelling-salts,  menthol  inhalations,  and  menthol- 
wool  are  all  effective.  These  failing,  or  as  supplementary  to 
them,  I  advise  gymnastic  exercise  of  the  nasal  dilator  muscles, 
and  once  or  twice  I  have  found  it  necessary  to  resort  to  faradism. 
If  unrelieved  all  the  former  symptoms  are  liable  to  recur. 

RHINOSCLEROMA. 

This  rare  disease,  which  may  be  considered  a  specific  hyper- 
trophy, and  is  not  limited  to  the  nose,  requires  only  a  passing 


RHINOSCLEROMA, 


579 


mention,  as  it  is  not  prevalent  in  Britain  ;  for  there  are  but  three 
reported  cases  seen  in  this  country,  one  being  that  of  a  boy  of 
fourteen,  a  native  of  Guatemala  (Semon),  the  others  of  a  brother  and 
sister,  also  of  foreign  nationality  (Robertson).  The  morbid  condi- 
tion consists  essentially  in  a  round-celled  infiltration  of  the  corium 
of  the  skin  which  appears  at  the  anterior  nares,  spreading  first 
of  all  to  the  alse  and  to  the  lips  ;  it  may  afterwards  invade  the  sub- 
mucosa  of  the  nasal  lining,  soft  palate,  pharynx,  and  larynx.  The 
over-lying  epithelium  appears  smooth  and  shining,  and  there  is  no 
tendency  to  ulceration.  To  the  touch  the  lesion  feels  like  a  hard 
cartilaginous  plate  or  plates ;  there  is  no  pain,  with  the  exception 
of  a  slight  tenderness  on  pressure.  Various  microbes  have  been  de- 
scribed as  present  in  the  infiltrated  areas,  and  Stepanowand  Niki- 
forow  claim  to  have  reproduced  the  disease  in  animals  from  culture 
of  a  bacillus,  which  they  regard  d.^  specific.  In  every  case,  with  one 
doubtful  exception,  in  which  surgical  measures  aiming  at  eradica- 
tion have  been  tried,  the  disease  has  recurred  ;  as,  however,  it 
does  not  invade  the  bones,  the  only  treatment  advisable  is  to 
combat  the  tendency  to  the  production  of  nasal,  pharyngeal,  and 
laryngeal  stenosis  by  appropriate  operative  procedures — trache- 
otomy, for  instance,  has  more  than  once  been  necessary.  Internal 
medication  w^ould  appear  to  be  useless. 

ATROPHIC  RHINITIS. 

Varieties :  Simple,  or  non-foetid,  and  specific,  or  foetid. 

The  literature  of  atrophic  rhinitis  is  so  voluminous  that  I  shall 
avoid  as  much  as  possible  quoting  authorities,  and  shall  content 
myself  with  stating  those  views  which  after  long  observation  I 
have  adopted  as  nearest  the  truth. 

The  terms  atrophic  and  dry  rhinitis,  implying  as  they  do  dessica- 
tion  and  shrinking  of  the  nasal  mucosa,  have  been  used  by  many 
writers  as  synonymous  with  ozsena.  Tubercular  and  syphilitic 
diseases  of  the  nose,  with  foetid  symptoms,  have  also  been  spoken 
of  as  ozaena,  so  that  the  term  has  been  applied,  even  by  special 
authorities,  and  quite  commonly  by  the  profession  at  large,  to 
represent  disease  per  se.  Ozaena  is,  however,  as  its  Greek  deri- 
vative, or  its  French  and  German  synonyms,  pitnaisie  and  stinknase, 
clearly  indicate,  but  a  symptom,  frequent  and  indeed  almost  con- 
stant in  atrophic  rhinitis  ;  occasional,  or  almost  infrequent  in  hyper- 
trophic rhinitis — both  non-ulcerative  diseases ;  and  invariable  in 
the  case  of  syphilitic  and  tubercular — ulcerative  diseases  of  the 
nose.    I  here  restrict  the  term  atrophic  rhinitis  to  a  dry,  non- 


58o 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ulcerative  shrinking  process  of  the  mucous  membrane  and  spongy 
bones,  characterized  by  abnormal  roominess  and  patency  of  the 
choanae,  diminished  secretion,  the  formation  of  crusts,  and  in 
most  cases  by  foetor,  the  last  symptom  being  manifested  in  vary- 
ing grades  at  varying  periods  of  the  disease. 

Etiology  and  Pathology. — The  atrophy  of  the  mucosa  is  seen 
histologically  to  consist  in  a  change  in  the  epithelium  from  a 
ciliated  to  a  squamous  variety ;  then  follows  fatty  degeneration 
resulting  in  atrophy  more  or  less  complete  of  the  serous  and 
mucous  glands,  and  in  a  cirrhosis  replacing  the  lymphoid  masses 
and  the  other  constituents  of  the  submucous  layer ;  there  is  also 
marked  thickening  of  the  walls  of  the  vessels  and  shrinking  of  the 
erectile  tissues.  These  changes  can  be  readily  made  out,  and  on 
this  head  most  observers  are  in  substantial  agreement,  and  in 
addition  Wyatt  Wingrave  has  recently  demonstrated  the  presence 
of  specific  bodies  resembling  protozoa  in  the  plasmodium  and 
sporing  stages,  which  in  his  judgment  constitute  the  essential 
difference  between  what  he  terms  the  tnie  or  progressive  atrophic 
rhinitis,  and  the  simple  or  pseido  form.  Whether  these  specific 
bodies  are  absolutely  causal  remains  yet  to  be  proved.  Indeed, 
opinions  of  all  the  foregoing  changes  are  of  the  most  diversified 
description. 

In  the  preceding  chapter  I  have  pointed  out  that  hypertrophy 
is  sometimes  the  antecedent  of  atrophy,  but  there  are  also 
numbers  of  cases  which  pass  into  an  atrophic  condition  without 
having  passed  through  a  previous  hypertrophic  stage.  Morell 
Mackenzie  probably  represents  a  large  consensus  of  opinion  when 
he  writes,  '  Atrophy  appears  to  be  always  a  secondary  affection.' 
My  own  notion,  however,  is  that  atrophy  is  often  primary,  in  the 
sense  of  not  being  secondary  to  any  previous  pathological  process 
in  the  nose,  although  in  such  cases  I  would  be  the  first  to  admit 
that  the  pathological  change  is  really  due  to  a  morbid  diathetic 
state  of  the  system  (associated  possibly  with  irritation  from 
particles  in  an  insanitary  atmosphere).  This,  however,  is  not 
what  Mackenzie  means,  for  he  is  distinctly  of  opinion  that  the 
disease  is  not  constitutional,  and  therefore  not  secondary  in  this 
sense.  I  think  I  have  satisfied  myself  that  in  a  number  of 
instances,  in  addition  to  a  predisposing  constitutional  weakness, 
which  is  usually  strumous  in  character,  two  other  factors  have 
been  present  as  excitants,  viz.,  abnormal  patency  of  the  anterior 
nares  with  an  upturned  condition  of  the  nose,  and  the  pretty 
constant  inhalation  of  an  insanitary  atmosphere.  As  regards  the 
patency  of  the  nostril  in  this  class  of  patients,  the  nose  is  nearly 


A  TROPHIC  RHINITIS. 


581 


always  'tip-tilted,'  not  from  any  morbid  process  in  the  septum,  as  is 
seen  in  ulcerative  syphilitic  diseases,  but  as  a  congenital  feature,  re- 
presenting a  defective  type  in  the  evolution  of  the  fronto-nasal  plate. 

Thus,  the  anterior  aperture  of  the  nostril,  instead  of  looking 
almost  directly  downw^ards,  looks  more  or  less  forwards,  thus 
allowing  the  air-current  to  pass  directly  into  the  inferior  meatus  ; 
which  is  at  the  same  time  favoured  by  the  greater  width  of  the 
nostrils,  by  the  absence  of  vibrissse,  and  by  the  wide  condition 
of  the  isthmus  between  the  vestibule  and  the  choanse,  the  usual 
constricting  band  being  absent  and  the  compressor  naris  paretic; 
while  per  contra  there  is  frequently  manifested  an  abnormal 
activity  of  the  dilator  naris.  These  factors  act  most  powerfully 
in  causing  the  incoming  air  to  pass  straight  through  the  inferior 
meatus  to  the  pharynx,  instead  of  passing  over  the  middle  and 
superior  parts  of  the  nasal  cavities ;  for  it  must  be  remembered 
that  unless  the  air  passes  upwards,  there  will  be  little  diffusion 
with  the  warmed  and  moistened  air  of  the  nasal  reservoirs  or 
accessory  sinuses.  The  mucosa  of  the  lower  parts  of  the  choanse 
will  be  overworked  and  rendered  more  irritable  to  the  particles  of 
an  insanitary  atmosphere.  Moreover,  if  there  be  any  strumous 
or  other  constitutional  vulnerability,  the  inability  to  recover  from 
slight  irritation  will  result  in  the  destruction  of  cilia,  and  in  con- 
sequent stagnation  and  drying  of  secretion  as  the  first  step  in  the 
pathological  process  of  so-called  idiopathic  atrophy.  I  have  used 
the  qualification  '  so-called it  is  clearly  a  misnomer  to  apply  the 
term  '  atrophy '  to  a  structure  which  has  never  been  satisfactorily 
developed,  for  in  these  instances  there  is  evidently  a  want  of  cor- 
relation between  the  growth  of  the  child  and  of  the  ethmoid 
structures.  Conversely,  we  have  a  '  so-called  '  hypertrophy  of 
the  nasal  structures  of  children  occurring  before  puberty,  in  which 
the  growth  of  the  turbinal  is  in  excess  of  the  growth  of  the  child. 

As  predisposing  factors  in  the  process  must  be  mentioned  age 
and  sex.  The  disease  is  most  prevalent  in  young  adults  of  the 
female  sex,  and  in  many  cases  first  becomes  objectively  evident  to 
non-medical  observers  about  the  age  of  puberty,  because  the  result- 
ing ozsena  is  more  marked  at  the  menstrual  periods.  But  not  only 
is  atrophic  rhinitis  to  be  found  in  individuals  who,  having  arrived  at 
puberty,  are  amenorrhaic,  and  in  later  years  perhaps  menorrhagic, 
but  I  have  seen  so  many  cases  of  the  disease  commencing  in 
young  children  at  the  age  of  seven  and  eight,  in  whom  the 
menstrual  epoch  has  afterwards  been  abnormally  delayed,  that 
I  cannot  doubt  the  causal  connection  between  wasting  or  non- 
development  of  the  erectile  tissues  of  the  nasal  fossae  and  a  similar 


582 


DISEASES  OF  THE  THROAT  AND  NOSE. 


condition  of  the  female  generative  organs.  I  have  also  satisfied 
myself  that  there  is  much  truth  in  J.  N.  Mackenzie's  view  as  to 
the  association  of  other  kinds  of  sexual  sympathy  and  irritation 
as  factors  of  nasal  disease  generally,  and  of  the  atrophic  form  in 
particular. 

As  regards  secondary  atrophic  rhinitis,  I  have  already  explained 
how  it  occasionally  follows  simple  non-foetid  hypertrophy.  Cases 
of  hypertrophic  rhinitis  which  become  complicated  by  foetor  pro- 
bably invariably  end  in  atrophy  from  the  irritation  of  the  essential 
ozsenic  factors,  to  be  presently  described.  Atrophy  is  sometimes 
secondary  to  suppurative  catarrh  of  the  antrum  from  dental 
disease ;  most  cases  of  unilateral  ozgena  are  of  this  nature,  though 
the  existence  of  a  similar  catarrh  of  the  frontal  sinus  must  be  also 
borne  in  mind.  Clinical  experience,  confirmed  by  cadaveric  and 
microscopic  examination,  has  assured  me  that  suppurative  dis- 
charges from  the  accessory  cavities  are  often  attended  by  a 
shrinking  of  the  tissues  and  bone  absorption.  As  previously 
stated,  although  dry  or  atrophic  catarrh  is  not  always  accom- 
panied by  ozaenic  symptoms  at  an  early  stage,  it  is  probable  that 
they  invariably  supervene  sooner  or  later. 

I  have  up  to  this  point  avoided  entering  into  the  question  of  the 
cause  of  the  ozaena.  If  we  were  dealing  with  a  disease  involving 
ulceration,  and  especially  ulceration  of  bone  (caries),  it  would  be 
easy  to  understand  the  presence  of  a  foul-smelling  odour ;  but  in 
true,  uncomplicated,  atrophic  rhinitis  there  is  no  ulceration  except 
such  as  is  artificially  produced  in  removing  crusts;  and  the  smell 
of  caries,  for  instance,  of  the  ethmoid  bone,  or  of  the  vomer,  is 
quite  unlike  the  unique  specific  foetor  known  as  ozaena.  Various 
explanations  as  to  the  cause  of  this  peculiar  foetor  have  been 
suggested,  of  which  the  following  only  are  worth  considering : 
(i)  It  has  been  held  to  be  due  to  suppurating  discharges  in  the 
accessory  sinuses ;  but  this  does  not  explain  why  this  specific, 
unique  odour  should  issue  from  the  sinuses.  Moreover,  it  is  rarely 
that  the  smell  of  pus  in  the  antrum  and  other  sinuses  is  truly 
ozaenic.  (2)  It  has  been  considered  due  to  the  fatty  degenerative 
changes  w^hich  admittedly  often  take  place  in  the  cells  of  the  race- 
mose glands.  (3)  In  recent  times  it  was  inevitable  that  an  explana- 
tion would  be  sought  for  in  the  direction  of  fermentative  changes, 
and  in  the  life  processes  of  micro-organisms.  Both  B.  and  E. 
Frankel  endeavoured  to  prove  the  latter  point  by  examining  plugs 
of  cotton-wool  which  had  remained  in  the  nose  for  some  hours  after 
they  had  been  introduced  by  Gottstein's  method.  They  found  a 
number  of  microbes  present.    Loewenberg  and  others  have,  how- 


ATROPHIC  RHINITIS. 


583 


ever,  pointed  out  that  in  such  an  experiment  only  an  aeroscopic 
cultivation  is  made  of  the  prevailing  organisms  in  the  atm.osphere 
w^hich  happened  to  be  present  in  the  nose  at  the  time.  Such  an 
experiment  failed  to  prove  specificity.  Loewenberg,  on  the  other 
hand,  claims,  as  the  result  of  his  cultivation  experiments  from 
ozaenic  crusts,  that  the  unique  foetor,  so  easily  recognised  yet 
hardly  to  be  described,  is  invariably  associated  with  the  presence 
of  a  large  diplococcus.  He  claims  to  have  found  it  always  present 
in  the  ozaena  which  occasionally  accompanies  hypertrophy,  as  well 
as  in  that  of  atrophy  of  the  mucosa.  He  has  never,  after  repeated 
cultivations,  found  it  present  in  those  simple  forms  of  rhinitis  in 
which  ozaenic  foetor  has  not  yet  appeared.  He  therefore  claims 
that  this  large  diplococcus  is  the  specific  cause  of  ozaena.  In 
some  recent  cases  which  I  have  had  bacteriologically  examined 
for  me,  the  organism  has  nearly  always  been  found. 

Whilst  feeling  strongly  that  all  such  advances  in  our  know- 
ledge must  ultimately  prove  of  practical  utility,  I  am  bound  to 
suggest  that  the  smell  is  so  characteristic  of  itself  that  it 
is  quite  unnecessary  for  diagnostic  purposes  to  look  for  the 
diplococcus,  and  Loewenberg's  discovery,  accepting  the  microbe 
to  be  the  cause  of  the  ozaenic  foetor,  brings  us  no  further  forward 
as  regards  treatment,  for  germicidal  and  deodorizing  therapeutics 
have  been  adopted  by  anticipation  for  many  years.  Loewenberg 
believes  that  the  diplococcus  finds  a  favourable  nidus  before 
ozaena  is  well  marked,  and  that  its  discovery  is  of  use  in 
diagnosing  those  cases  of  hypertrophy  which  are  likely  to 
terminate  in  atrophy  before  foetor  has  appeared.  Proof  of  this 
is  unfortunately  just  what  is  wanting  at  present,  and  such  an 
authority  on  the  nose  as  Bosworth  does  not  believe  that  atrophy 
is  ever  a  resulting  sequela  of  hypertrophy,  an  opinion  which  is, 
however,  quite  contrary  to  my  own  experience.  I  have,  for 
example,  now  under  my  care  a  case  of  such  great  hypertrophy  of 
the  left  middle  turbinal  that  it  has  displaced  the  septum  and 
produced  atrophy  of  the  tissues  on  the  right  side ;  and  simultaneous 
occurrence  of  the  two  is  indeed  quite  common. 

I  am  myself  in  the  habit  of  differentiating  the  true  ozaenic 
odour  from  (i)  the  foetor  of  pus  met  with  in  suppurative  catarrh 
of  the  sinuses,  especially  in  polypus  and  in  hypertrophy ;  (2)  from 
that  due  to  decomposition  of  retained  and  inspissated  secretions 
forming  the  crusts  of  atrophic  rhinitis ;  and  (3)  from  the  smell 
associated  with  carious  processes  in  the  bone  and  cartilage  in 
connection  with  syphilis,  tuberculosis,  and  with  various  poisons 
causing  loss  of  tissue  of  the  rhinal  structures. 


584  DISEASES  OF  THE  THROAT  AND  NOSE. 


Not  only  can  these  odours  to  my  sense  be  distinctly  differen- 
tiated, but  their  behaviour  under  the  use  of  a  deodorant  douche 
constitutes  a  diagnostic  point  of  almost  unfailing  constancy  and  ot 
importance,  (i)  In  the  case  of  pus  there  will  be  no  malodour  for 
upwards  of  twenty-four  hours  after,  and,  moreover,  the  patient  is 
made  conscious  of  its  reaccumulation  by  taste  and  nausea.  (2) 
Thorough  removal  of  the  crusts  and  free  douching  will  render 
the  subject  of  ozaena  due  to  atrophic  rhinitis  quite  fit  for  societ}^ 
provided  the  process  is  unremittingly  pursued  twice  every  twenty- 
four  hours,  except  perhaps  at  or  near  to  the  catamenial  period, 
when  it  should  be  pursued  more  frequently,  since  at  this  time  the 
stench  is  always  more  intense.  Another  diagnostic  point  is  that 
the  subject  of  atrophic  rhinitis  is,  as  a  rule,  unaware  of  the  dis- 
agreeable character  of  the  breath.  (3)  When  there  is  actual 
caries  or  necrosis,  the  deodorizing  effect  of  irrigation  is  very 
evanescent ;  the  smell  is,  moreover,  far  more  penetrating,  and  is 
also  a  constant  factor  of  discomfort  and  distress  to  the  patient. 

Treatment  is  always  tedious,  and  often  most  unsatisfactory ; 
but  I  cannot  admit  that  it  is  always  hopeless,  as  is  so  generally 
asserted.  The  younger  the  patient  the  more  likely  is  treatment 
to  be  successfuL  In  cases  which  occur  after  the  period  of  puberty, 
and  as  the  probable  result  of  a  chronic  hypertrophy  of  a  pernicious 
blood  supply,  the  sequel  of  a  fever,  the  prospects  of  success  are 
less  encouraging. 

Remedial  measures  that  may  be  pursued  by  the  patient  are 
fourfold  :  (i)  by  syringing  and  spraying,  to  moisten  the  incrusta- 
tions and  retained  secretions,  never  attempting  to  remove  them 
by  force  or  without  such  previous  softening  ;  (2)  by  further  washing 
with  anterior  or  posterior  douches,  to  clear  away  the  same  ;  (3)  by 
inunctions,  to  obviate  the  continuance  of  the  dessication  of  the 
mucus  and  the  re-formation  of  the  scabs ;  (4)  by  modifying  the 
undue  patency  of  the  nostrils  and  providing  a  substitute  for  the 
shrunken  turbinals.  With  this  view  I  have  advantageously  pre- 
scribed the  insertion  into  the  nostril  of  lightly-carded  fragments 
of  wool  medicated  with  iodol  or  menthol.  All  of  these  remedies 
may  be  made  to  assist  in  a  general  antiseptic,  detergent,  or 
oxygen-generating  process  ;  and  for  this  purpose  several  formulae 
are  appended. 

The  main  point  in  treatment  is  to  insist  on  the  necessity  of 
perseverance  ;  it  may  even  require  to  be  pursued  for  the  rest  of 
the  patient's  life  ;  and  as  individuals  are  seldom  conscious  of  the 
offensive  character  of  the  breath,  I  always  encourage  them  not  to 
be  averse  to  a  reminder  from  friends  and  relatives  when  there  is  a 


ATROPHIC  RHINITIS. 


585 


relapse,  so  that  renewed  activity  in  remedies  may  be  exercised. 
In  any  case  douches  and  inunction  should  be  employed  night  and 
morning,  and  occasionally  at  noon  also.  Beyond  these  local 
measures,  the  constitutional  defects  must  be  carefully  combated 
by  appropriate  drugs,  diet,  and  hygiene.  Development  of  de- 
layed menstrual  function  and  correction  of  all  causes  of  an 
excessive  catamenial  flow,  are  points  to  be  never  omitted  in  the 
treatment  of  ozsena  in  females.  The  constant  galvanic  current 
is  serviceable  in  restoring  tone,  and  has  been  claimed  when 
applied  locally  to  effect  an  absolute  cure.  Residence  at  Weston- 
super-Mare  has  proved  of  advantage  in  several  children  who 
have  been  educated  there  by  my  advice.  The  exhalations  from 
the  mud  of  the  Channel  in  that  district  are  said  to  be  of  value  on 
account  of  its  bromo-iodine  constituents. 

The  question  remains,  Can  the  disease  be  cured  ?  The  answer 
lies  in  the  view  taken  of  the  morbid  process.  Granted  that  when 
once  the  ciliated  epithelium  and  vascular  tissue  are  destroyed 
they  cannot  be  replaced,  and  that  therefore  the  normal  character 
of  the  membrane  can  never  be  restored,  much  may  be  done  to 
counterbalance  this  loss  by  stimulation  to  more  active  capillary 
circulation,  and  this  especially  where  the  diseased  condition 
appears  to  be  due  to  retrograde  changes  consequent  on  arrest  of 
development  rather  than  to  actual  atrophy.  In  no  way  can  this 
desirable  end  be  so  effectually  achieved  as  by  occasional  light 
searings  with  the  galvano-cautery,  so  as  to  set  up  active  granula- 
tion. This  process  may  be  reinforced  by  stimulating  inunctions, 
as  of  iodoform,  iodol,  or  menthol.  I  am  happy  in  the  experience 
of  many  cases  in  which  perseverance  in  such  a  course  has  been 
rewarded  by  a  large  measure  of  success,  amounting,  indeed, 
practically  to  a  cure.  It  is  true  that  in  many  cases  the  patient 
has  been  obliged  to  continue  the  employment  of  the  douches  and 
inunctions  just  indicated ;  but  the  chief  and  most  distressing 
symptom — namely,  the  ozcena — has  been  thereby  completely 
nullified,  while  the  dryness  of  the  throat,  the  deafness,  headache, 
and  digestive  disorders  have  all  been  reduced  to  a  minimum. 

Several  specialists,  notably  Hunter  Mackenzie  and  Bronner, 
have  pointed  out  the  value  of  direct  irritation  of  the  turbinal 
bodies  as  a  remedial  agent  of  importance,  the  former  recom- 
mending the  introduction  into  the  nostrils  of  little  rolls  of  a 
cantharidine  plaster  known  as  *  canthos  cotton the  latter  the 
application  of  trichloracetic  acid  in  a  spray. 

I  have  seen  beneficial  results  from  both  these  measures,  espe- 
cially the  former,  combined — be  it  always  remembered — with 


586 


DISEASES  OF  THE  THROAT  AND  NOSE. 


the  persevering  use  of  antiseptics  diffused  by  the  coarse  spray  ; 
and  the  success  has  been  the  greater,  the  higher  the  social  grade 
of  the  patient,  in  which  class  apathy,  the  great  obstacle  to  per- 
manent improvement,  is  less  likely  to  prevail. 

Braun  has  advocated  massage,  by  special  small  instruments, 
v^ith  a  view,  I  presume,  to  encourage  nutrition ;  and  Garnault  of 
Paris  has  supported  him  in  his  reports,  which  are  of  a  somewhat 
confident  nature. 

Atrophic  Rhinitis  depending  on  syphilis  will  be  considered 
under  the  heading  of  perforation  of  the  septum,  while  that  arising 
as  a  result  of  either  lupus  or  lepra  has  been  alluded  to  in 
Chapter  XX.,  which  treats  of  those  diseases  in  the  regions  of  the 
throat.    A  few  more  words  may  be  added. 

Lupus. — The  liability  for  the  nose  to  be  early  attacked  is  ex- 
plained by  Hunt,  in  a  recent  paper  of  much  original  interest,  to  be 
due  to  its  proneness  to  abrasion  during  nasal  catarrh,  and  for  the 
same  reason  of  greater  susceptibility  to  trauma  he  attributes  the 
preference  of  the  uvula  and  epiglottis.  This  author  thinks  that 
in  cases  of  nasal  lupus  the  disease  really  originates  often  in  the 
mucous  membrane  and  spreads  outwards  to  the  skin — a  point 
very  difficult  to  settle.  Moreover,  there  appears  to  be  a  prone- 
ness for  lupus  to  attack  by  preference  parts  in  which  cartilage 
predominates.  There  is,  however,  but  Httle  doubt  in  my  mind 
that  though  such  may  be  the  case  in  the  rare  instances  in  which 
the  throat  is  attacked  before  the  skin,  the  more  usual  sequence 
is  for  the  mucous  membrane  to  be  invaded  secondarily,  and 
in  my  judgment  this  is  simply  by  contiguity.  There  is  little 
evidence  to  favour  the  view  that  it  is  conveyed  any  distance 
through  the  lymphatics,  or  by  absorption.  Hutchinson  has 
explained  that  the  reason  why  lupus  is  so  much  more  destructive 
of  tissue  in  the  alae  and  septum  of  the  nose,  lips,  and  soft  palate, 
and  I  might  add  epiglottis  and  ventricular  bands,  and  also  of  the 
ear,  is  that  the  ulceration  spreading  by  continuity  attacks  the  two 
opposite  surfaces  of  these  regions  almost  concurrently.  This  fact 
is  of  diagnostic  value  in  differentiating  from  persistent  herpes, 
lichen,  eczema,  and  true  tubercle.  The  cases  in  which  an 
invasion  of  lupus  extends  beyond  the  cartilage  and  attacks  the 
nasal  bones  are  so  rare  as  to  imply  serious  doubt  whether  it  ever 
occurs  except  there  be  a  co-added  syphilitic  history. 

Case  3. — M.  M  ,  aged  46,  female,  presented  herself  at  the  Central  Throat  and 

Ear  Hospital  on  January  nth,  1892,  complaining  of  '  pain  in  her  throat '  of  two  months' 
duration.  She  had  suffered  with  nasal  stuffiness  for  eight  or  nine  years,  and  had  been 
under  treatment  for  polypus  of  the  nose,  for  lupus  of  the  nose,  and  for  inflamed  ankle 


ATROPHIC  RHINITIS. 


587 


joint,  the  nature  of  which  was  obscure.  She  was  also  the  subject  of  frequent 
'  gatherings '  on  her  fingers,  general  debility,  and  *  colds  in  the  nose.'  Had  been 
delivered  of  one  child,  which  was  born  at  the  eighth  month,  and  lived  four  weeks  only. 

State  on  admission  :  Has  a  very  unpleasant  smell  from  her  nose,  a  persistent  tickling 
in  her  throat,  especially  when  in  bed,  and  her  mouth  is  always  dry  in  the  morning.  She 
cannot  appreciate  the  smell  of  strong  coffee,  tea,  or  cooked  meats. 

Both  nostrils  were  found  to  be  obstructed,  the  left  more  than  the  right.  In  the  ri£-/if 
is  seen  an  irregular,  bright  pink,  spongy  granulation  mass,  apparently  springing  from  a 
hypertrophied  septum.  The  middle  turbinal  cannot  be  seen,  but  the  inferior  is  observed 
to  be  swollen  and  pale  in  contrast.  The  /<?//  nostril  is  chiefly  occupied  by  similar  granu- 
lation masses,  growing  from  the  middle  turbinal.  They  are  paler  than  those  on  the 
septum  in  the  right  nostril,  and  readily  bleed  on  probing.  The  inferior  turbinal  on  this 
side  is  also  hypertrophied,  and  still  paler  than  the  new  tissue.  There  is  well-marked 
pharyngitis  lateralis. 

Has  not  lost  weight  and  is  not  troubled  with  night  sweats.  The  lungs  are  normal, 
with  the  exception  of  some  harsh  breathing  over  both  apices.  The  expectoration  is 
rather  free,  but  contains  no  bacilli  of  tubercle  and  no  elastic  tissue. 

A  portion  of  the  growth  from  the  middle  turbinal  was  removed,  and  on  examination 
Mr.  Wingrave  fotyid  as  follows  : 

•  The  greater  part  of  the  structure  removed  consists  of  small  cell-inflammatory  tissue, 
covered  with  plain  columnar  and  columnar  ciliated  epithelium.  Mucoid  degeneration  is 
well-marked  in  some  places,  whilst  in  others  masses  of  cell-clusters  are  seen,  resembling, 
and  possibly  identical  with,  "giant  cells."  Blood-vessels  are  plentiful,  and  their  walls 
show  marked  fibrosis,  whilst  here  and  there  epitheloid  proliferation  has  blocked  the 
lumen.  Very  little  erectile  tissue  can  be  made  out,  as  it  is  invaded  by  the  small  cells. 
Cyst-like  invaginations  of  columnar  epithelium  are  shown  in  several  of  the  sections, 
whilst  normal  mucous  acini  are  fairly  numerous.  Lastly,  the  bone  and  periosteum  are 
found  to  be  perfectly  healthy,  excepting  that  here  and  there  the  small  cell  tissue  appears 
to  be  invading  the  cancellous  spaces.     TJm-e  is  no  nec7-osis' 

The  treatment  adopted  was  that  of  curetting,  and  free  appH- 
cation  of  a  60  per  cent,  solution  of  lactic  acid,  the  parts  having 
been  previously  well  cocainized.  She  made  an  excellent  recovery, 
and  on  March  20th,  1893,  fifteen  months  after  she  first  came 
under  my  care,  she  presented  herself  again  at  the  hospital,  and 
reported  that  she  was  quite  well. 

Although  this  patient  has  shown  unusual  recuperative  powers, 
still  a  tedious  progress  of  the  disease  is  a  strong  indication  of  the 
case  being  one  of  true  lupus,  and  the  unusual  rapidity  of  repair  is 
equally  against  the  diagnosis  of  lupus  or  true  tuberculosis.  The 
presence  of  giant-cell  tissue  must  make  one  watch  with  interest 
the  future  development.  A  point  of  favourable  prognosis  in  this 
case  is  that  no  tubercle  bacilli  were  found,  but  indeed  their 
presence  is  but  very  rarely  detected  in  any  case  of  lupus. 

Lepra  of  the  Nose  is  even  more  common  than  in  the  larynx, 
and,  indeed,  epistaxis  is  probably  the  first  symptom  that  the 
mucous  membrane  of  the  upper  air-passages  is  affected.  Hillis, 
who  holds  this  opinion,  has  recorded  one  case  in  which  'the 
patient's  nose  bled  long  before  he  knew  he  was  a  leper.'  In 


588 


DISEASES  OF  THE  THROAT  AND  NOSE. 


three-fourths  of  the  cases  tabulated  by  this  observer  more  or  less 
nasal  disease  was  present.  The  actual  conditions  were  very 
various,  and  comprised  hyperaemia  and  infiltration  of  the  mucous 
membrane,  tuberculation  of  the  turbinated  bodies,  destruction 
of  the  septum,  and  of  the  whole  cartilages,  and  with  stenosis 
of  the  nasal  orifices. 

Tuberculosis  may  also  be  manifested  in  the  nares,  but  there 
are  no  special  grounds  for  separate  remarks,  except  that  it  is 
exceedingly  rare,  and  it  is  doubtful  if  it  is  ever  primary.  Its 
local  manifestations  would  be  best  reheved  by  menthol,  iodol,  or 
aristol  in  ethereal  or  oily  sprays,  and  by  other  antiseptics  or 
sedatives,  administered  by  means  of  medicated  wools,  or  by 
oro-nasal  inhalers. 

RHINITIS  CASEOSA. 

This  is  a  curious  nasal  condition,  in  which,  as  the  name  implies, 
the  upper  part  of  the  nasal  choanse  are  blocked  by  a  caseous, 
putty-like  material ;  it  is  found  either  in  debilitated  strumous 
subjects  or  as  a  sequence  of  polypi.  As  far  as  I  am  aware,  no 
satisfactory  account  has  been  given  of  the  pathology  of  this  con- 
dition ;  it  does  not  seem  either  like  degenerated  polypi  or  mucous 
membrane,  but  rather  as  a  fatty,  long-retained,  morbid  secretion, 
originating  in  the  superior  meatus,  or  in  the  frontal,  ethmoidal 
and  sphenoidal  sinuses.  Hill  informs  me  that  he  has  in  five 
instances  during  three  years  observed  the  sphenoidal  sinus 
nearly  filled  with  this  caseous  material  in  dissection-room  sub- 
jects of  advanced  years,  in  which  no  bone  disease  was  evident.  I 
have  seen  but  three  cases  in  the  living  subject  who  have  applied 
for  relief.  The  condition  is  an  obstinate  one,  and  usually  asso- 
ciated in  my  experience  with  some  caries  of  the  ethmoid  bone. 
Anosmia  and  headache  are  prominent  symptoms,  but,  curiously 
enough,  foetor  is  not  always  marked. 

Treatment. —  I  should  recommend  persistent,  but  careful 
scooping  away  of  the  masses  and  curetting  of  the  sphenoidal  and 
ethmoid  cells,  when  such  a  procedure  is  possible.  The  coarse 
spray  should  be  frequently  used  with  some  antiseptic  lotion,  and 
constitutional  medication  and  a  generous  diet  should  never  be 
omitted.  The  prognosis  is  favourable,  if  both  surgeon  and  patient 
will  persevere  to  complete  eradication  of  the  disease. 


MORBID  CONDITIONS  OF  THE  SEPTUM. 


589 


II.   MORBID  CONDITIONS  OF  THE  SEPTUM  AND 
OSTEO-CARTILAGINOUS  FRAMEWORK. 

Before  considering  the  diseases  of  this  portion  of  the  nose,  it 
may  be  well  to  treat  with  more  detail  than  has  already  been 
afforded  the  structure  of  the  septum. 

The  septum  must  be  considered  as  consisting  of  two  portions, 
the  cartilaginous  and  the  osseous.  The  former,  as  seen  in  the 
child,  consists  of  two  parts — the  upper  portion  being  formed  in 
the  mes-ethmoid  plate  as  a  single  layer  ;  the  lower  consisting  of 
two  laminae  formed  in  membrane  round  the  ethmo-vomerine 
cartilage,  which  is  subsequently  absorbed. 

The  two  laminae  as  a  rule  unite,  but  under  some  circumstances 
may  remain  bi-laminar  ;  this  has  an  important  surgical  signifi- 
cance. 

The  ethmo-vomerine  plate  is  received  below,  between  the  two 
halves  of  the  maxillary  bone,  and  the  horizontal  plate  of  the 
palate ;  the  former  frequently  expands,  and  this  produces  a 
distinct  ridge. 

These  laminae  of  bone  probably  represent  those  special  struc- 
tures Potiquet  described  as  the  sub-vomerine  bones,  which  arise 
independently  of  the  maxilla ;  but  their  homologues  not  being 
found  in  the  lower  animals,  it  is  only  fair  to  infer  that  this 
arrangement  represents  an  aberration. 

The  cartilaginous  portion  is  simply  the  unossified  remnant 
of  the  cartilaginous  ethmo-vomerine  plate.  The  cartilage  of 
Jacobson  has  already  been  referred  to  on  page  37. 

Recalling  to  the  reader  what  has  been  said  at  page  36,  it  may 
be  added,  that  with  regard  to  the  mucous  membrane  of  the 
septum  itself,  numerous  glands  of  both  the  albuminous  and 
mucous  type  are  freely  distributed  over  its  whole  extent.  This 
is  a  fact  which  is  not  to  be  found  in  text  books,  and  to  which 
the  writer's  attention  has  been  drawn  by  his  colleague,  Wyatt 
Wingrave. 

Haematoma  of  the  Septum  is  the  result  of  traumatism,  and 
ma}^  be  either  bilateral  or  unilateral,  in  my  experience  generally 
the  latter.  There  is  frequently  general  oedema  of  the  nose  ex- 
ternally, with  the  swelling  extending  to  the  forehead  and  even  to 
the  lids  and  cheeks.  The  blood  accumulates  between  the  mucous 
membrane  and  the  osteo-cartilaginous  framework.  It  may  be 
mistaken  for  polypus.  If  unrelieved  by  aspiration  or  incision,  the 
blood-tumour  is  either  gradually  absorbed,  or  else  it  terminates 


DISEASES  OF  THE  THROAT  AND  NOSE. 


in  Abscess  of  the  Septum.  This  latter  condition  is  not,  however, 
always  preceded  by  haematoma,  for  traumatism  may  lead  to  carious 
conditions  of  the  bone  or  cartilage,  which  go  on  to  perforation  and 
a  symmetrical  suppuration,  in  which  case  evacuation  of  pus  is  of 
course  indicated.  Haematoma  may  be  confounded  with  a  syphilitic 
gumma  of  the  septum  :  such  a  cause  should  be  suspected  where 
there  is  no  history  of  trauma,  and  appropriate  local  and  consti- 
tutional treatment  adopted,  incisions  being  of  course  contra- 
indicated. 

PERFORATIONS  OF  THE  SEPTUM. 

Perforations  of  the  septum  as  part  of  the  operative  treatment  of 
some  forms  of  obstructive  deviations  are  sometimes  affected  pur- 
posely, sometimes  inadvertently.  The  small  openings  thus  made 
are  often  productive  of  great  relief  to  stenotic  symptoms,  are 
never  followed  by  any  destructive  ulceration,  and  generally  the 
patient,  unless  informed,  is  unaware  of  their  existence.  The 
time  is  now  gone  by  when  all  perforations  of  the  septum,  ex- 
cepting those  of  traumatic  origin,  are  regarded  as  evidences  of 
a  syphilitic  dyscrasia.  Syphilitic  perforation  is  probably  always 
associated  with  necrosis  of  some  portion  of  the  ethmoid  bone  in 
addition  to  the  perpendicular  plate,  and  foetor  is  never  absent. 
It  may  commence  as  a  gumma.  The  following  cases,  which 
came  under  my  notice  on  the  same  day,  at  a  visit  to  the 
hospital,  are  illustrations  of  this  form  of  specific  perforation  in 
the  adult. 

Case  i. — M.  B  ,  aged  50  (registered  No.  76,350),  presented  herself  at  the  hospital 

January  27,  1890,  complaining  of  having  suffered  pain  for  the  last  year  on  the  left  side  of 
the  throat,  especially  on  swallowing,  and  excessive  purulent  discharge  from  the  nostril. 
Her  voice  was  toneless  and  her  articulation  thick.  On  examination,  the  whole  of  the  left 
side  of  the  soft  palate  and  a  portion  of  the  right  was  seen  to  have  been  destroyed  by 
ulceration,  and  a  large  perforating  ulcer  existed  at  the  situation  of  the  left  tonsil.  The 
septum  nasi  was  perforated  to  the  size  of  a  threepenny-bit,  and  ulceration  was  still 
active.  She  had  suffered  from  dimness  of  vision  for  three  years,  and  was  at  present  the 
subject  of  choroiditis  of  the  left  eye.  It  was  elicited  on  further  interrogation  that  of  seven 
children,  three  had  been  born  dead,  two  had  survived  but  a  few  weeks,  and  the  last  two 
were  living  and  comparatively  healthy. 

The  eroding  process  was  arrested  by  local  galvano-cauterization  to  both  septum  and 
palate,  the  use  of  iodol  ointment  to  the  nose  and  chlorate  of  potash  as  a  gargle  to  the 
throat,  together  with  the  internal  administration  of  the  biniodide  of  mercury. 

Case  2. — M.  B— — ,  aged  24,  dressmaker  (registered  No.  76,341),  applied  on  the  same 
day  as  above,  complaining  only  of  pain  in  the  nose,  from  which  she  had  suffered  for  two 
years.  On  examination,  the  septum  was  found  to  be  deviated  to  the  left  side,  and  perfo- 
rated by  ulceration,  which  had  evidently  commenced  on  the  right  side,  and  had  extended 
through  so  as  to  produce  ulceration  of  both  the  left  inferior  and  left  middle  turbinated 
bodies.  Although  it  was  difficult  to  obtain  an  absolute  'specific '  history  in  this  case,  the 
fact  was  elicited  that  there  had  been  a  suspicious  skin  eruption,  loss  of  hair,  and 


PERFORATIONS  OF  THE  SEPTUM, 


591 


'inflamed  lumps'  (nodes)  on  the  shin  bones.  Improvement  took  place  under  the  internal 
administration  of  biniodide  of  mercury  and  the  local  application  of  nitrate  of  silver, 
followed  by  ointment  of  iodol. 

On  the  other  hand,  the  perforations  met  with  in  strumous 
persons  are  usually  limited  to  the  triangular  cartilage,  and  the 
erosive  process  shows  no  disposition  to  attack  the  bony  septum. 
Such  perforations  frequently  result  from  the  practice,  not  only  in 
children,  but  also  in  adults,  of  picking  the  nose ;  it  is  probable 
that  the  irritation  which  induces  picking  is  caused  by  hairs,  and 
by  accumulations  and  crusts  on  slight  spurs,  so  frequently  the 
cause  of  epistaxis,  and  the  process  of  erosion  and  haemorrhage, 
thus  set  up,  eventually  leads  to  perforation  of  the  triangular 
cartilage.  These  openings,  though  sometimes  large,  rarely  give 
rise  to  deformity  or  falling  in  of  the  nose,  which  is  rather  the  rule 
in  syphilis,  unless  energetically  treated  at  the  initial  stages. 

Another  class  of  perforations  are  those  resulting  from  haemor- 
rhagic  and  debilitating  illnesses,  such  as  typhus  and  small-pox, 
and  are  not  uncommon  in  those  who  have  resided  in  India,  or 
other  hot  climates.    The  following  represent  types  of  this  class. 

Case  3. — C.  A  ,  aged  24,  a  waiter,  consulted  me  a  short  lime  ago  for  a  perforation 

of  the  septum.  He  had  a  severe  attack  of  variola  between  the  ages  of  two  and  three 
years.  As  long  as  he  can  remember  he  has  always  '  felt  something  the  matter  with  his 
nose.'  At  various  periods  there  has  been  a  discharge  from  the  nostrils,  sometimes  offen- 
sive.   His  senses  of  smell  and  taste  are  '  not  so  good  as  they  were.' 

On  examination,  there  were  the  usual  appearances  of  perforated  septum,  evidently  of 
long  standing.  In  its  present  state,  and  probably  for  a  long  time  past,  the  inconvenience 
experienced  was  not  due  to  any  advance  of  the  ulcerative  process,  but  to  retention  and 
inspissation  of  the  secretions,  leading  to  the  formation  and  deposit  of  crusts. 

It  appears  evident  from  the  history  and  appearance,  that  this  condition  resulted  from 
the  attack  of  small-pox  at  the  age  of  two  years. 

The  treatment  adopted  was  a  nasal  spray  of  iodol  and  menthol  in  olive  oil,  and  an 
ointment  containing  15  grains  of  iodol  to  5i  of  vaseline. 

Case  4. — Dr.   ,  aged  42,  of  the  Army  Medical  Staff,  consulted  me  in  1886  on 

account  of  a  small  perforation  in  the  cartilaginous  septum.  He  stated  that  he  had  always 
been  subject  to  slight  erosions  and  incrustations  inside  the  nose.  These  he  had  picked 
away,  with  the  result  generally  of  causing  slight  haemorrhage.  While  serving  a  few 
months  ago  in  the  Soudan,  he  perceived  one  morning  that  the  septum  had  given  way,  and 
a  small  hole  was  formed  which  had  since  increased  to  its  present  size — a  quarter  of  an  inch 
in  diameter.  Ulceration  had  been  for  some  time  arrested.  I  advised  simple  inunction 
to  prevent  the  further  formation  of  crusts. 

Perforation  from  chromic  acid  and  phosphorus  poisoning,  or 
from  the  virus  of  malignant  types  of  fevers,  is  an  acute  process 
which  rapidly  destroys  the  cartilage,  but  only  infrequently  causes 
marked  destruction  of  bone.  Deformity  is  only  an  occasional 
result ;  and  bone  is  never  attacked,  except  in  the  case  of  syphilis 
or  leprosy,  and — very  rarely — in  that  of  lupus. 


592 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Case  4. — A  female,  aged  24,  came  under  my  care  early  in  1887  at  the  hospital  on 
account  of  a  nasal  perforation,  which  she  stated  had  originated  as  a  sequel  of  vaiiola. 
Anti-syphilitic  treatment,  which  she  had  undergone  at  the  hands  of  another  specialist, 
had  only  increased  her  suffering,  and  continual  application  of  mercurial  ointment  had 
led  to  frequent  epistaxis. 

Treatment. — In  addition  to  constitutional  measures  directed 
against  any  specific  dyscrasia,  and  generous  diet,  energetic  local 
medication  in  the  shape  of  antiseptic  sprays,  and  unguents  or 
bougies  of  iodol  or  sozo-iodol  with  cocaine  are  indicated  ;  and 
cessation  of  any  habit  likely  to  keep  up  irritation  is  to  be  rigor- 
ously enforced.  The  entire  closing  of  a  perforation  by  healing 
process  is  unknown  in  my  experience,  and  it  is  doubtful  if  such 
a  happy  result  ever  occurs ;  but  spontaneous  or  induced  arrest 
of  ulceration  is  the  rule. 

DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM. 

Independently  of  the  seriously  disfiguring  external  deformities 
that  result  from  violent  accidents  to  the  nose,  well-marked  deflec- 
tions and  bony  and  cartilaginous  outgrowths  or  spurs  of  the 
septum,  to  be  seen  only  on  anterior  rhinoscopic  examination,  are 
exceedingly  common,  and  constitute,  in  spite  of  repeated  records, 
a  still  generally  unrecognised  or  unacknowledged  cause  of  grave 
nasal  trouble,  or  of  a  distressing  reflex  disturbance. 

A  perfectly  symmetrical  septum  would  appear,  from  the  observa- 
tions of  Zuckerkandl,  M.  Mackenzie,  and  others,  to  be  the  excep- 
tion rather  than  the  rule.  Thus,  out  of  a  total  of  2,276  skulls 
examined  by  Mackenzie,  Theile,  Semeleder,  and  Harrison  Allen, 
there  was  conspicuous  deviation  in  about  75  per  cent.  In  370 
crania  inspected  by  Zuckerkandl,  there  were  spurs  or  deflections 
in  140,  that  is,  in  37*8  per  cent. ;  whilst  the  proportion  between 
symmetrical  and  asymmetrical  septa  in  Europeans  is'  as  i  to  3, 
but  in  the  Aborigines  of  Africa,  America,  and  Australasia  it  is 
as  4  to  I,  a  curious  and  somewhat  significant  fact.  It  must 
be  understood  that  these  statistics  apply  to  deviations  (of  more 
than  half  a  millimetre)  of  the  bony  septum,  and  do  not  include 
deformities  of  the  cartilaginous  septum.  A  large  number,  how- 
ever, of  the  anterior  spurs  on  which  I  have  operated  during  the 
last  few  years,  and  of  which  I  have  kept  records,  were  cartila- 
ginous, and  it  is  therefore  evident  that  the  numbers  deducible 
from  the  examination  of  dried  skulls  understate  the  frequency  of 
septal  deviations.  On  the  other  hand,  we  have  no  extensive 
or  reliable  statistics  on  a  large  scale  of  the  proportion  of  cases  of 
septal  deformity  which  cause  symptoms  requiring  operative  relief, 
to  the  whole  number  of  cases  of  nasal  disease,  and  of  the  number 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM.  593 


of  cases  which  are  aggravated,  but  not  actually  caused,  by  the 
septal  asymmetry.  Of  200  cases  of  nasal  obstruction  tabulated 
by  my  colleague,  Dundas  Grant,  there  were  septal  deviations 
of  such  magnitude,  position,  or  hyper-sensibility  as  to  be  considered 
the  source  of  one  or  more  symptoms  in  33*5  per  cent.  These 
deviations  were  associated  with  hypertrophic  rhinitis  in  27*5  per 
cent.,  and  uncomplicated  in  6  per  cent,  of  the  whole  number. 


Drawing  made  from  Specimen  in  Army  Medical  Mitseinn,  Washington.    No.  2,247. 

Fig.  CXCVI. — Coronal  Section,  showing  septum  deviated  to  the  left,  with 
osteo-ecchondrosis  or  spur  (probably  traumatic)  ascending  obliquely  along  upper 
vomerine  suture.  The  outgrowth  is  most  marked  in  the  inferior  meatus.  On  account 
of  the  slightly  sigmoid  character  of  ihe  deviation,  there  is  an  enlargement  of  the  right 
inferior  and  left  middle  meatus,  with  compensatory  hypertrophy  of  their  respective 
turbinals. 

The  left  middle  turbinated  body  has  been  sectionized  so  as  to  show  its  cavity  : 
the  antral  cavities  are  seen  to  be  somewhat  asymmetrical. 

As  regards  age,  Zuckerkandl's  statement  that  the  septum  is 
rarely  deflected  before  the  seventh  year  is  at  variance  with  older 
notions,  though  the  fact  that  it  is  quoted  without  question  by 
eminent  authorities  would  appear  to  show  that  it  is  corroborated 
by  clinical  experience.  Probably  this  immunity  in  early  years  of 
life  can  be  readily  explained  on  anatomical  and  physiological 

38 


I 


594  DISEASES  OF  THE  THROAT  AND  NOSE. 

grounds.  Certainly  the  youngest  case  in  which  I  have  found 
it  necessary  to  operate  was  that  of  a  httle  boy  eleven  years  of 
age,  and  his  septal  deviation  was  directly  due  to  traumatism  (fall 
from  a  wall)  five  years  previously.  The  point  is  such  an  im- 
portant one  that  further  observations  in  other  countries  would  be 
interesting,  whether  confirmatory  or  otherwise. 

Etiology.— Numerous  causes  have  been  assigned  as  accounting 
for  these  deformities,  excluding  true  fractures,  which  usually  take 
place  along  the  upper  border  of  the  vomer,  and  are  due  to  marked 


I^'-awifig  made  from  Specitiioi  in  Army  Medical  Museum.  IVashingtoii.    No.  2,348. 

Fig.  CXCVIL— Coronal  Section,  made  posteriorly  to  that  of  the  preceding  figure, 
through  the  lesser  wings  of  the  sphenoid.  Here  also  is  shown  a  sigmoid  deviation, 
but  the  spur  on  the  left  side  is  somewhat  obscured  by  shading.  There  is  especially 
marked  thickening  of  the  perpendicular  plate  of  the  ethmoid.  The  openings  of  the 
upper  ethmoidal  cells  are  well  shown,  and  the  general  asymmetry  of  the  turbinated 
bodies,  so  commonly  existing,  is  well  demonstrated. 

traumatism.  Deviations  with  buttress-like  spurs  have  been  con- 
sidered to  be  caused  by  such  slight  traumatic  influences  as  using 
the  handkerchief  with  the  same  hand  and  sleeping  on  a  certain 
side,  and  a  method  of  manipulative  treatment  to  correct  external 
deformity  has  been  founded  on  these  hypotheses. 

The  appearance  of  a  deviated  septum  examined  post-mortem 
almost  irresistibly  points  to  the  conclusion  that  the  deflected 
septum,  unconnected  w^ith  traumatism,  is  usually  an  overgrown 
septum  ;  in  other  words,  there  is  want  of  correlation  between  the 
growth  of  the  septum  and  the  rest  of  the  bony  framework.  An 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM. 


S95 


arched  palate  with  deviation  of  the  septum  may  be  taken  as  an 
example  of  want  of  correlation  in  growth  between  various  parts 
of  the  bony  framework.  In  such  a  case  a  septum  of  normal 
growth  and  dimensions  becomes  deflected  because  a  previous 
deviation,  associated  with  earlier  ossifications  of  the  palatal  pro- 
cesses of  the  maxillary  and  palatal  bones,  has  reduced  the  vertical 
diameter  of  the  nasal  fossae.  A  deviated  septum  is  frequently  to 
be  seen  in  mouth-breathers  at  about  the  age  of  puberty,  in  asso- 
ciation with  hypertrophies  of  the  pharyngeal  tonsil  and  narrow, 
highly-arched  palates.  I  am  not  in  a  position  to  speak  definitely 
as  to  the  causal  connection  of  these  complicated  cases.  Probably 
the  palatal  defect  has  predisposed  to  the  glandular  hypertrophy. 

Mayo  Collier,  in  an  able  paper  read  before  the  British 
Laryngological  and  Rhinological  Association  (Transactions  of  the 
British  Laryngol.  and  Rhinol.  Association,  vol.  i.,  1891,  p.  75), 
arguing  that  where  the  septum  is  thinnest  deflections  are,  and 
where  thickest  they  are  not,  believes  that  in  the  blocking  of  one 
nostril  from  whatever  cause,  the  air  in  it  is  rarefied  by  each 
inspiratory  act,  and  if  rarefied  the  walls  of  that  nostril  are 
subjected  to  a  pressure  exactly  in  proportion  to  the  amount  of 
rarefaction.  .  .  .  This  combined  and  long-continued  pressure  at 
right  angles  to  the  nasal  septum  can  hardly  fail  to  push  in  the 
thin  wall  of  the  nasal  fossa  at  its  weakest  point. 

This  contention  is  very  plausible  and  decidedly  applicable  to 
some  cases,  as,  for  instance,  those  of  children,  in  which  a  deflection 
of  the  soft  cartilaginous  or  ill-developed  bony  septum,  whether  or 
no  the  original  cause  be  traumatism,  is  set  right  without  direct 
surgical  treatment,  or  the  re-establishment  of  free  nasal  respiration, 
by  the  removal  of  associated  turbinal  hypertrophy. 

But  it  does  not  provide  for  those  more  common  traumatic  cases 
in  adults,  in  which  there  is  dislocation  of  the  cartilage  from  the 
bony  septum,  which  appears  to  have  led  to  a  corrective  inflamma- 
tory process,  and  a  support  to  the  weaker  side,  by  the  develop- 
ment of  a  buttress-like  hypertrophy  to  be  presently  described. 

Deviations  of  the  septum  are  often  sigmoid  in  character,  either 
in  a  horizontal,  vertical,  or  oblique  plane  ;  further,  the  convexity 
of  the  deviation,  especially  when  this  presents  a  line  of  suture 
between  bones  or  cartilage,  is  frequently  increased  by  the  throw- 
ing out  of  a  cartilaginous,  bony,  or,  more  commonly,  osteo- 
cartilaginous buttress  or  spur.  Such  spurs  are  usually  present 
when  a  deflected  septum  gives  rise  to  obstructive  symptoms. 
Spurs  do  not  necessarily  arise  opposite  lines  of  suture,  but  such  is 
generally  the  case.    In  my  experience  the  commonest  form  need- 


596 


DISEASES  OF  THE  THROAT  AND  NOSE. 


in^  operative  interference  is  what  Holbrook  Curtis  calls  an  oblique 
ascending  deviation  and  thickening,  which  passes  along  the 
suture  of  the  upper  border  of  the  vomer  with  the  triangular 
cartilage  and  with  the  perpendicular  plate  of  the  ethmoid.  A 
horizontal  spurred  deviation  is  also  frequent  at  the  suture  of  the 
maxillary  crest  with  the  cartilage  and  with  the  lower  border  of  the 
vomer.  The  form  usually  met  with  is  a  spur  at  the  anterior  part  of 
the  choanae,  composed  chiefly  of  cartilage,  which  projects  into  and 
often  closes  the  inferior  meatus  through  contact  with  the  inferior 
turbinated  body.  Vertical  spurs  are  the  rarest  form,  and  are 
associated  with  deflections  showing  a  sigmoid  curve  in  the  hori- 
zontal plane  from  before  backwards. 

Deflections,  while  causing  stenosis  of  the  meatus,  into  which 
they  protrude,  naturally  increase  the  patency  of  the  opposite  side  ; 
but  increase  of  function  is  apt  to  render  the  turbinated  bodies  on 
this  open  side  liable  to  compensatory  hypertrophy.  This  secondary 
overgrowth  or  vascular  turgescence  may  take  place  to  such  an 
extent  that  stenosis  will  be  produced,  which  will  demand  treat- 
ment ;  but  it  often  happens  that  a  deviated  septum  having  been 
rectified,  the  compensatory  hypertrophy  of  the  turbinals  of  the 
opposite  side  will  spontaneously  undergo  partial  and  sufficient 
resolution. 

Fracture  may  result  in  dislocation  along  the  upper  or  lower 
border  of  the  vomer,  the  former  being  most  usual  and  generally 
restricted  to  the  anterior  part.  Fracture,  however,  greenstick  or 
otherwise,  with  or  without  dislocation,  may  occur  anywhere.  The 
triangular  cartilage  is,  of  course,  the  part  ordinarily  displaced, 
and  when  this  happens  there  is  alw^ays  internal  and  often,  though 
not  universally,  external  deformity  also.  My  own  experience 
enables  me  to  entirely  concur  with  those  writers  who  believe  that 
traumatism  is  the  most  important  factor  in  the  production  of 
septal  deviations,  especially  in  the  adult,  and  any  difference  of 
opinion  on  this  point  may  be  at  least  partially  explained  by  the 
circumstance  that  so  many  years  often  elapse  between  the  injury 
and  the  development  of  symptoms  which  demand  relief,  that  the 
primary  cause  is  often  forgotten,  and  will  only  be  elicited  by  cross- 
examination.  My  case-book  teems  with  records  of  such  examples. 

Symptoms  (Objective). — External  deformities,  such  as  de- 
pression of  the  bridge  and  lateral  deviations  of  the  tip,  are  rarely 
marked  except  after  violent  injuries.  Internal  deformity  is  rendered 
evident  on  anterior  and  posterior  rhinoscopic  examination,  and 
often  on  external  and  internal  digital  examination.  Sometimes 
the  full  extent  of  the  deviation  only  becomes  evident  after  the 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM. 


597 


reduction  of  erection  of  the  soft  tissues,  by  means  of  cocaine,  or  of 
hypertrophy  and  growths  by  the  cautery,  snare  and  other  appro- 
priate measures,  or  by  the  removal  of  an  anterior  spur.  The 
position  and  consistence,  as  tested  by  probing,  renders  the 
diagnosis  complete.  With  ordinary  care,  abscess  and  hsematoma 
are  unlikely  to  be  mistaken. 

Cases  of  deafness  and  tinnitus,  and  even  of  auditory  vertigo, 
not  infrequently  come  under  notice  in  w^hich  it  is  exceedingly 
difficult  to  pass  a  Eustachian  catheter  on  account  of  septal  de- 
viation, and  many  ingenious  modifications  of  this  instrument  have 
been  devised  for  overcoming  the  obstruction  ;  but  the  circumstance 
has  not  yet  received  general  recognition  as  indicative  of  a  condition 
calling  for  surgical  interference.  Were  such  the  case,  it  would 
often  be  found  that  rectification  of  the  septum  not  only  enables 
the  catheter  to  be  passed  with  ease,  but  in  the  majority  of  cases 
renders  its  further  use  unnecessary — in  other  words,  the  deafness 
and  other  aural  symptoms  are  cured  or  greatly  alleviated  so  soon 
as  free  nasal  respiration  is  re-established. 

Associated  with  nasal  stenosis  due  to  septal  deviation,  as  also 
in  that  which  may  arise  from  hypertrophic  rhinitis,  the  pharynx 
and  upper  part  of  the  larynx  are  unduly  congested.  Wherever 
the  narrowing  is  considerable,  paresis  of  the  soft  palate,  elongation 
of  the  uvula,  varix  of  the  root  of  the  tongue  and  hypertrophy  of 
the  lingual  tonsil,  with  the  attendant  symptoms  of  impairment 
of  voice,  and  of  faucial  and  pharyngeal  tenesmus,  will  also  be  noted. 

Holbrook  Curtis  {Joitrn.  of  Amer.  Med.  Association,  Jan.  ii, 
i8go)  has  impressed  upon  the  profession  the  causal  relation- 
ship of  ancEuiia  and  nasal  stenosis,  a  circumstance  that  I  have 
often  noticed,  and  the  importance  of  which  I  have  frequently  in- 
sisted on  in  practice.  It  is  to  be  first  observed  that  subjects  of 
nasal  obstruction,  whether  the  cause  thereof  be  cartilaginous 
deflection  and  spurs,  intra-nasal  polypi,  or  naso-pharyngeal  hyper- 
trophies, are  alw^ays  white-blooded.  The  actual  deficiency  of  oxy- 
hsemoglobin  in  such  subjects  may  be  demonstrated  by  means 
of  Henocque's  ingenious  hsematoscope,  and  Curtis  has  reported 
twenty  cases  in  which  the  deficiency  before  operation  w^as  proved 
by  means  of  this  instrument  to  be  reduced  from  the  normal  of 
14  per  cent,  to  as  low  as  5'5,  and  in  one  case  to  3*5  per  cent. 
After  relief  of  the  stenosis,  improvement  took  place  to  the 
extent  of  a  regain  of  oxy-haemoglobin  in  some  instances  of 
even  double  the  former  diminished  quantity.  Spirometrical  ex- 
periments and  other  measurements  show  corresponding  de- 
ficiencies and  improvements  in  the  vital  capacity,  chest-girth, 


598 


DISEASES  OF  THE  THROAT  AND  NOSE. 


and  weight.  These  facts  are  of  supreme  importance  as  to  the 
possibihty  of  this  anaemia  due  to  nasal  stenosis  being  a  predis- 
ponent  to  tubercle.  Cardiac  depression  may  also  be  explained  on 
a  similar  hypothesis. 

The  Subjective  symptoms  are  those  of  unilateral  or  bilateral, 
partial  or  complete,  nasal  obstruction,  and  are,  as  previously 
mentioned,  frequently  complicated  by  chronic  and  hypertrophic 
catarrh,  polypi,  hay  asthma,  and  other  reflex  phenomena,  the  last 
being  especially  noticeable  when  the  spur  actually  touches  and 
irritates  either  the  middle  or  inferior  turbinals.  The  functions 
of  taste,  smell,  hearing,  and  voice-production  are  impaired. 
Headache  and  aprosexia,  and  any  or  many  of  the  near  and  remote 
symptoms  of  nasal  stenosis  mentioned  in  the  previous  chapter, 
may  be  present. 

Treatment. — When  the  deviation  is  due  to  traumatism,  and  is 
of  the  nature  of  a  dislocation  or  fracture,  much  may  be  done 
if  the  condition  comes  under  the  notice  of  the  surgeon  at  once. 
In  cases  of  long  standing,  Adams's  operation  of  refracturing  the 
septum  and  supporting  it  in  position  by  intra-nasal  splints  or 
bougies  is  rarely  productive  of  very  brilliant  results  as  regards  the 
deformity  for  which  it  is  indicated,  and  to  which  it  should  be 
restricted.  I  have  not  myself  encouraged  such  a  severe  procedure 
for  external  deformity  alone.  Nevertheless,  it  is  seldom  that  such 
a  case  is  uncomplicated  by  defects  of  function  in  the  shape  of 
anosmia,  deafness,  faulty  voice-production,  etc. 

These  can  be  effectually  relieved  by  removal  of  the  obstructing 
part  of  the  septum  by  means  of  a  nasal  saw,  or  by  a  circular 
trephine  driven  by  a  surgical  engine  or  electro-motor.    I  know  of 
no  innovation  in  modern  rhinological  practice  for  the  relief  of 
(hard)  nasal  obstructions  to  which  I  am  so  much  indebted  as 
to  CiLrti&^ -nasal  trephines.    Spurs  of  large  size  can  be  reduced  at 
one  sitting  with  little  pain  under  cocaine.    Any  projections  re- 
quiring further  treatment  may  be  removed  with  the  small  nasal 
saw.     The  haemorrhage  is  sometimes  considerable,  but  rarely 
alarming,  and  I  have  always  been  able  to  check  it  by  either 
douching  with  hot  water,  or  closely  plugging  the  nostril  with 
cotton-wool  pledgets  soaked  in  a  15  or  20  per  cent,  solution  of 
cocaine   or   antip}rin.     Some   practitioners   dilate    the  nasal 
passage  at  the  same  time,  either  with  bougies  or  tubes,  but 
these  are  seldom  used  by  me  for  the  first  fourteen  days.  Nasal 
splints  for  correcting  a  sigmoid  deflection  of  the  cartilaginous 
septum  in  the  adult  are,  in  my  experience,  rather  disappointing, 
and  liable  to  set  up  painful  inflammation.    But  in  young  children 


DEVIATIONS  AND  DEFOKMITIES  OF  THE  SEPTUM.  599 


I  have  seen  good  results  with  Dundas  Grant's  instrument.  Since 
I  first  witnessed  Curtis  operate  by  trephine  on  sixteen  cases  in 
one  afternoon  in  the  ordinary  out-patient  cHnic  of  my  hospital,  I 
have  given  up  treatment  by  cautery,  incisions,  or  punches. 

RQSWortli  claims  to  have  only  once  perforated  a  septum  in 
sawing  operations,  the  number  of  which  would  appear  in  his 
practice  to  amount  to  thousands.  Indeed,  he  made  that  state- 
ment several  years  ago,  and  repeats  it  with  all  his  increased 
experience  in  his  quite  recently  published  magnuni  opus.  I  can 
hardly  believe  that,  dwelling  so  strongly  as  he  does  on  the 
importance,  in  correction  of  a  deformed  septum,  of  achieving 
a  perfectly  smooth  surface,  that  failure  to  entirely  eradicate  a 
spur  would  explain  such  a  unique  immunity  to  perforations. 
It  is  the  personal  opinion  of  many  that  not  only  is  it  often 
impossible  to  correct  a  deviation,  whether  by  trephine  or  saw, 
without  perforating  the  partition,  but  that  such  a  procedure  is 
in  some  instances  of  sigmoid  flexures  the  only  means  to  bring 


Fig.  CXCVIII. — Dundas  Grant's  Splint  for  Straightening  Deflections 

OF  THE  Septum. 

about  the  restoration  of  a  breath-way  in  both  nostrils.  Looking, 
moreover,  to  the  comparative  frequency  of  septal  perforations, 
unassociated  with  any  dyscrasise,  caries,  or  necrosis,  and  their 
non-liability  in  such  circumstances  to  cause  deformity — a  point 
correctly  insisted  on  by  Bosworth  himself — one  hardly  sees  why 
a  perforation  should  be  so  much  dreaded. 

Hewetson  of  Leeds,  recognising  the  fact  that  with  cautery,  saw, 
and  "snare^we  are  in  some  instances  forced  to  be  content  with 
only  partially  relieving  an  obstinate  stenosis,  boldly  proceeds  to 
rapidly  dilate  the  nasal  choanae,  under  an  anaesthetic,  with  a 
powerful  dilator,  acting  on  the  principle  of  a  glove- stretcher. 
Hewetson  has  enlarged  the  nasal  passages  by  these  means  in 
more  than  300  cases  with  marked  success,  and  without  any 
untoward  incidents.  I  have  now  operated  on  several  cases  in 
which  no  treatment  short  of  a  crushing  dilatation  would  have 
been  of  much  use  in  relieving  obstruction,  and  the  results  have 
been  most  gratifying.    Amongst  these  are  included  many  which 


6oo 


DISEASES  OF  THE  THROAT  AND  NOSE. 


had  been  imperfectly  relieved  by  trephine  and  sa  A^,  but  were 
cured  by  forcible  dilatation.  The  crushing  of  the  turbinated 
bodies  and  bones  and  fracture  of  the  outer  wall  of  the  aasal  fossa, 
which  must  take  place  in  some  instances,  appear  to  give  rise  to 
no  troublesome  symptoms. 

Not  the  least  of  the  merits  of  Hewetson's  operation  is  that 
the  constricting  band,  causing  anterior  stenosis  by  shutting  off 


Fig.  CXCIX. — Hewetson's  Nasal  Dilator,  with  Author's  Modifications. 

[Half  ineasuremcnt. ) 


The  roughened  ends  prevent  slipping,  and  the  oval  opening  is  made  so  that  the  instru-  . 
ment  can  be  used  as  a  straightener  of  septal  displacement,  which  is  sometimes  an  i/jime- 
diate  result  of  forcible  dilation. 

the  vestibule  from  the  choanae,  is  by  the  nasal  dilator  forcibly 
stretched,  and  the  entrance  to  the  nasal  chambers  appreciably 
enlarged.  If  Grant's  tubes,  of  a  short  pattern,  be  worn  for  a 
month  or  two  after  forcible  dilation,  the  collapse  of  the  alas 
frequently  disappears.  In  other  cases  further  stimulating  measures 
as  mentioned  in  relation  to  hypertrophic  rhinitis  may  be  called 
for. 


Fig.  CC. — Hill's  Nasal  Dilator  and  Septum  Straightener. 
^Hcilf  iiwasiircments.) 


Hill  has  devised  a  modification  of  Hewetson's  instrument, 
which  possesses  the  combined  principles  of  both  Hewetson's 
dilators  and  Adams's  septum  straightener.  The  screw  working  on 
a  measured  scale  is  an  original  idea  of  decided  value.  I  have 
ventured  to  add  another  slight  improvement,  in  having  both  the 
outer  and  inner  surface  of  the  blades  roughened.    By  this  means 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM.  6or 


in  dilating  the  instrument  is  prevented  from  slipping,  and  in 
straightening  of  the  septum  a  firmer  grip  is  obtained.  I  have 
also  applied  the  same  principle  to  Hewetson's  instrument,  w^ith 
the  result  of  making  it  more  generally  serviceable.  Both  these 
instruments  might  be  bent  on  the  same  plane  as  Grant's 
straightener,  so  as  to  enable  the  surgeon  to  see  better  what  he 
W3iS  doing  with  them. 

Cases  with  favourable  results  have  been  reported,  in  which  the 
septal  deviations  have  been  reduced  by  electrolysis,  but  the  writer 
has  no  personal  experience  of  so  tedious  a  method  of  treatment, 
and  may  venture  the  opinion,  that  when  the  obstruction  is  of 
surgical  importance,  this  remedy  can  be  hardly  adequate  to  the 
occasion. 

The  following  cases,  which  could  be  multiplied  ten  or  even 
twenty  fold,  and  are  taken  almost  haphazard  from  the  notes  of 
my  private  practice,  are  briefly  narrated  for  several  reasons  : 

1.  As  examples  of  the  most  ordinarily  witnessed  varieties  of 

deviations. 

2.  As  indicating  the  nature  of  the  symptoms  usually  present. 

3.  As  illustrations  of  the  frequency  of  traumatism  as  an  etio- 

logical factor  of  deformity  of  the  septum  ;  and  of  the  length 
of  time  that  often  elapses  between  the  accident  and  the 
resultant  inconvenience. 

4.  To  exemplify  various  methods  of  treatment. 

5.  And  lastly,  by  pictorial  illustration  to  give  some  idea  of  the 

appearances  presented  to  view  in  anterior  rhinoscopic  ex- 
amination. 

With  regard  to  these,  it  may  be  thought  that  because  I  have 
objected  to  anterior  nasal  diagrams  for  general  use,  on  the  ground 
that  it  is  impossible,  on  any  one  conventional  plan,  to  represent  a 
full  perspective  of  the  receding  nasal  fossae,  these  drawings  are 
contradictory  of  that  position  ;  but  in  point  of  fact,  my  sketches 
aim  only  at  giving  a  general  and  somewhat  composite  delineation 
of  deflections  of  the  nasal  fossae  as  looked  at  from  the  several 
points  of  view  necessary  for  complete  examination,  this  necessi- 
tating visual  inspection  not  only  from  the  right  and  left  of  the 
middle  line,  but  also  in  the  separate  axes  of  the  superior  middle 
and  inferior  choanae. 

It  is  important  to  note  that  all  these  drawings  were  made  on 
cocainized  patients,  and  for  the  most  pait  represent  actually  less 
stenosis  than  really  existed.  In  all  the  cases  submitted  to  opera- 
tion I  had  the  advantage  of  the  co-opeiation  of  my  colleague 
Mr.  Jakins. 


6o2 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Fio.  CCI. 


Casp:  I  (Fici.  CCI.). — That  of  a  medical  friend  practising  in  Lancashire,  who  con- 
sulted me  in  1887.  The  drawing  represents  a  very  large  septal  spur  almost  completely 
obliterating  the  lumen  of  the  inferior  meatus,  which  is  still 
further  obstructed  by  hypertrophy  of  the  inferior  turbinated 
body,  A  small  spur  at  the  site  of  junction  of  the  maxillary 
crest  with  the  triangu'ar  cartilage  is  seen  on  the  right  side.  The 
following  is  the  patient's  history  in  his  own  words  :  '  When  14 
years  old  (I  am  now  46)  I  was  kicked  on  the  left  side  of  the 
nose  by  an  unshod  ass;  the  immediate  result  was  "two  lovely 
black  eyes,"  and  a  swollen  nose  ;  and  it  was  soon  afterwards 
noticed  that  my  nose  had  altered  its  shape  ;  but  I  felt  little  or  no 
inconvenience  till  I  was  26,  when  I  found  my  nostrils  stuffed  up. 
I  was  said  to  have  polypus,  and  an  attempt  was  made  to  re- 
move something  with  forceps.  I  suff'ered  much  pain,  lost  a  bucketful  of  blood,  but  of 
course  derived  no  benefit.  Until  I  saw  you  1  was  still  under  the  impression  that  I  had 
polypus. 

'The  symptoms  are  mainly  those  of  discomfort  when  walking  quickly,  which  occasions 
me  to  keep  my  mouth  open,  and  makes  me  liable  to  get  sore  throat  in  very  cold  or  dry 
weather.  I  have  great  irritation  in  the  nostrils  and  back  of  the  throat.  Whilst  in 
America,  at  the  meeting  of  the  Congress,  the  usually  dry  character  of  the  air  produced 
an  irritation  which  was  distinctly  painful.  I  am  not  only  liable  to  head  colds,  but  I 
think  I  have  them  more  severely  than  any  of  my  patients  ;  my  greatest  discomfort,  how- 
ever, is  at  night,  when  after  a  short  time  the  nostril  of  the  side  upon  which  I  lie  becomes 
so  obstructed  as  to  occasion  change  of  attitude,  and  when  I  turn  over  I  am  obliged  to 
breathe  through  the  mouth  for  some  time  before  nasal  respiration  is  restored.  Restless 
nights  are  therefore  very  frequent.  Sitting  up,  or  on  my  back,  I  can  generally  breathe 
with  my  mouth  closed.  The  auial  trouble  came  on  very  gradually,  in  fact  I  was  fairly- 
deaf  before  I  noticed  it ;  there  is,  as  you  know,  indrawing  of  the  drum-head  of  both  ears, 
due,  I  suppose,  to  unequal  air-pressure.  I  do  intend,  with  your  kind  help,  to  have  done 
vi^hat  you  advise,  but  wait  till  "a  more  convenient  season."  ' 


Case  2. — Dr.  J.  J.  T.,  aged  35,  practising  in  Wales,  consulted  me 
on  account  of  extreme  inconvenience  arising  from  mouth-breathing, 
especially  vi'hen  rowing,  running,  or  riding  ;  he  stated  that  twenty 
years  previously  he  had  had  a  blow  on  the  nose  from  football  on  tw'o 
separate  occasions,  first  on  one  side  and  then  on  the  other.  He  had 
had  a  severe  fall  on  the  face  when  he  was  6  years  of  age.  The  draw- 
ing illustrates  a  double  spur  at  the  suture  of  the  septum  and  the 
maxillary  crest.  The  patient  suff'ered  also  from  varix  of  the  veins  at 
the  base  of  the  tongue,  and  stated  that  he  always  arose  in  the 
morning  with  some  blood  in  the  mouth,  evidently  from  this  situa- 
tion. 


Case  3. — Mrs. 


Fig.  CCIII. 


C.  N.,  cet,  34,  from  Edinburgh,  consulted  me  in  October,  1888,  on 
account  of  increasing  tendency  to  nasal  catarrh,  dry  throat  in  the 
morning,  fatigue  of  voice  after  singing  or  reading,  paroxysmal  cough, 
headache,  and  restless  nights.  I  found  the  right  inferior  meatus 
blocked  by  a  large  spur,  with  general  hypertrophy  of  the  mucous 
membrane  of  this  side  ;  paresis  of  the  soft  palate  and  lingual  varix 
were  also  present,  and  the  mucous  membrane  of  the  larynx  was  con- 
gested and  inclined  to  be  thickened.  The  spur  was  sazvu  off  as 
indicated  by  the  dotted  line  in  the  diagram,  and  the  other  condi- 
tions treated  at  a  later  date  by  the  galvano-cautery,  sprays,  etc.,  all 
with  the  most  satisfactory  result. 


9 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM. 


603 


Case  4. — Master  T.,  xt.  11^,  from  (iloucestershire,  recommended  to  concult  me  by 
Dr.  Sampson  of  Painswick,  on  account  of  mouth-breathing.  His 
father  was  the  subject  of  hypertrophic  rhinitis,  slight  middle-ear 
deafness  and  a  tendency  to  asthma.  The  history  of  the  child  was, 
that  five  years  previously  he  had  fallen  from  a  wall,  violent  haemor- 
rhage occurred,  and  the  nose  was  much  swollen  afterwards.  On 
examination  I  found  a  sigmoid  deviation  and  thickening  of  the 
septum  as  indicated  in  the  figure,  together  with  adenoid  vegetations 
in  the  naso-pharynx. 

These  latter  having  been  removed,  the  deviation,  which  was  quite 
soft,  was  rectified  by  forcible  straightening,  the  wearing  of  Grant's 
splints  for  several  hours  a  day,  and  the  plugging  with  medicated  lint  in  the 


intervals. 


By  these  measures  not  only  was  natural  breathing  re-established,  but 
had  threatened  to  become  serious  was  corrected. 


deformity  which 


Case  5  is  that  of  a  lady,  set.  75,  recommended  to  consult  me  by 
Dr.  Bezley  Thorne.  Although  the  spurs  delineated  in  the  figure 
were  the  undoubted  cause  of  considerable  nasal  distress  and  reflex 
respiratory  irritation,  having  regard  to  her  advanced  age,  I  coun- 
selled only  palliative  treatment  in  the  shape  of  iodol  ointment  and 
menthol  inhalations. 


Case  6. — Mr.  J.,  ?et.  29,  a  solicitor,  consulted  me  on  the 
recommendation  of  Mr.  Greig-Smith  of  Bristol.  He  com- 
plained of  deafness  and  tinnitus,  weakness  of  voice,  and  especially 
fatigue  on  reading  aloud  long  documents,  dryness  of  mouth  in  the 
morning,  and  other  symptoms  of  nasal  stenosis.  The  drawing 
(Fig.  CCVI.)  represents  an  unusual  amount  of  thickening  and 
deviation  of  the  septum,  as  well  as  polypoid  hypertrophy  of  the 
turbinated  mucosa. 


Fig.  CCV 


Fig.  CCVI. 


Case  7. — T.  R.  B.,  Commander,  R.N.,  age  36,  came  under  my  care  in  May,  1887,  on 
account  of  failure  in  resonance  of  voice  and  great  hoarseness,  and  fatigue  on  the  least  exer- 
tion, so  that  it  was  almost  impossible  for  him  to  give  the  word  of  command  in  tones  that  could 
be  heard,  and  this  to  an  extent  that  constituted  a  serious  impediment  to  his  professional 
career. 

He  also  complained  of  constant  dryness  of  the  throat.   Although  he  admitted  that  trau- 
matism was  probable,  he  could  not  remember  any  definite  occa- 
sion on  which  he  had  received  a  blow  on  the  nose.    I  found,  in 
addition  to  a  sigmoid  flexion  of  the  septum,  a  very  considerable 
prominence  amounting  to  a  definite  spur  on  the  left  side,  and  varix 
at  the  base  of  the  tongue.    The  spur  I  sazved  oft",  and  the  varicose 
vessels  were  cauterized  at  a  later  date.    The  result  of  the  treat- 
ment is  best  given  in  a  letter  received  from  the  patient,  July  22nd 
of  the  same  year*:  '  I  have  not  had  the  slightest  trouble  with  my 
throat  since  I  last  saw  you  ;  my  voice  is  getting  much  stronger,  my 
nose  is  well,  and  I  feel  sure  that  when  you  next  see  me  you  will 
be  quite  satisfied  that  the  operation  has  been  in  every  way  a  success.'    This  gentleman 
went  through  the  manoeuvres  of  1888.    After  which  experience  he  wrote  :  '  I  am  only 
now  beginning  to  realize  the  amount  of  good  you  have  done  me.    In  spite  of  the  filthy 


CCVII. 


6o4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


weather  we  have  been  having,  and  the  lot  of  shouting  I  have  had  to  go  through,  my 
throat  has  not  given  me  the  slightest  bit  of  trouble,  and  my  voice  seems  to  be  getting 
stronger  and  better  every  day.'  He  again  served  in  the  manoeuvres  of  1889  without  any 
relapse,  and  quite  recently  expressed  himself  as  feeling  his  throat  stronger  and  better 
than  it  ever  was  before. 


Case  S.- 


Mr. W.  M.  J.,  set.  40,  a  publican  from  Liverpool,  sought  advice  in  September, 
1889,  for  the  relief  of  post-nasal  catarrh,  which  had  existed  for  twelve 
years  ;  he  remembered  to  have  had  a  violent  blow  on  the  nose  from 
a  cricket-ball  at  the  age  of  15.  The  figure  (CCVIII.)  shows  a 
thickened  deviation  of  the  septum,  evidently  the  result  of  fracture 
producing  direct  stenosis  of  the  left  choanse.  Stenosis  on  the  right 
side  was  also  present,  the  result  largely  of  compensatory  hyper- 
trophy. The  stenosis  in  this  case  was  completely  cured,  and  the 
symptoms  relieved  by  means  forcible  nasal  dilatation  with  Hewet- 
sons  instrument. 


Case  9. 


-Rev.  J.  G.,  aet.  35,  seven  years  in  holy  orders,  consulted  me  on  account  of 
his  voice  continually  failing  him.  Although  not  previously  aware 
of  it,  he  was  utterly  unable  to  breathe  through  the  left  nostril, 
and  on  being  quesiioned  remembered  that  he  had  had  a  severe 
blow  on  the  left  side  of  the  nose  nine  years  previously  when 
playing  at  football  at  Cambridge.  Fig.  CCIX.  shows  a  uni- 
lateral ascending  deviation  of  the  septum  along  the  suture  of  the 
triangular  cartilage,  and  the  vomer  completely  blocking  the  left 
nostril,  and  on  the  right  side  there  is  a  small  spur  at  the  junction 
of  the  triangular  cartilage  with  the  maxillary  crest.  Treatment 
consisted  in  trephining  on  both  the  right  and  left  sides  as  indi- 
cated in  the  figure  ;  the  operation  on  the  left  side  was  completed  by  means  of  the  saiv. 
The  result  was  satisfactory  above  all  expectation. 

Case  10. — Major  T.,  age  48,  retired  from  active  service  and  superintending  a  Govern- 
ment department,  consulted  me  on  June  4th,  18S8,  cn  account  of 
failure  of  voice,  disturbed  sleep  through  mouth  breathing,  dry  throat, 
fulness  of  head  after  a  very  short  period  of  official  occupation,  in 
fact,  of  aprosexia  in  a  marked  degree.  I  found  a  spur  on  ihe  right 
side,  and  a  great  general  thickening  of  the  septum  on  the  left,  the 
cause  of  which  condition  was  attributed  to  having  had  his  face 
trodden  on  when  playing  football  nearly  twenty  years  previously  ; 
there  was,  however,  no  external  disfiguration.  The  spur  on  the 
right  side  was  sawn  away,  and  the  thickening  on  the  left  cauterized. 
On  November  ist,  1888,  he  wrote  :  '  Since  you  took  me  in  hand,  I 
have  been  enjoying  an  amount  of  comfort  such  as  I  had  not  known 
for  years,  and  shall  ever  feel  sincerely  grateful  to  you  for  it.' 

Case  11.— The  Rev.  W.  S.,  an  Irish  priest,  age  51,  and  a  powerful  man,  measuring  six 
feet  five  inches  in  height,  and  weighing  271  pounds,  was  seen  by  my 
friend  Mr.  Jakins  in  my  absence  in  June,  1887,  on  account  of  failure 
of  voice,  which  had  existed  eighteen  months,  with  irritation  and 
dryness  of  the  throat.  His  breathing  power  was  considerably 
impaired.  His  symptoms  were  explained  by  a  relaxed  condition  of 
his  soft  palate,  which  was  probably  secondary  to  almost  absolute 
obstruction  of  his  left  nostril,  due  to  a  somewhat  bi-lobed  septal 
ecchondroma.  Traumatism,  though  highly  probable  on  account  of 
certain  personal  proclivities,  was  not  inquired  into.  Relief  by 
palliatives  to  the  fauces  was  such  that  radical  treatment  was  not 
adopted. 


Fig.  CCX. 


Fic.  CCXI 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM. 


605 


Fig.  CCXII. 
consulted  me  with 


Fig.  CCXIII. 


Cask  12. — Major  P.,  age  38,  consulted  me  in  June,  1887,  on  account  of  general  nasal 
discomfort  and  disturbed  sleep,  from  which  he  had  markedly  suffered 
for  two  or  three  years.  Though  on  inquiry  it  was  found  that  nasal 
respiration  had  never  been  entirely  free  since  he  struck  his  nose  by 
running  against  a  wire  fence  on  a  dark  night  in  the  year  1874.  On 
examination  I  found  a  large  spur  entirely  obstructing  the  inferior 
breathway  of  the  left  nostril  and  a  bi-lobed  cartilaginous  thickening 
on  the  right  aspect  of  the  septum. 

The  left  nostril  was  treated  by  trephine  and  saw,  the  right  by  saw 
alone,  as  indicated  by  the  dotted  lines  in  the  figure. 

He  made  an  excellent  recovery,  and  was  entirely  relieved  of  all 
his  distress. 

Case  13. — Mr.  F.  H.,  age  39,  retired  officer  from  the  army, 
symptoms  very  similar  to  the  last  patient,  and  at  about  the  same 
period  of  the  year. 

There  was  complete  obstruction  of  the  left  nostril  by  reason  of 
an  antero  posterior  sigmoid  deviation  of  a  highly  thickened  septum, 
and  of  the  inferior  meatus  of  the  right  by  a  distinct  spur. 

On  inquiry  it  was  found  that  he  had  had  a  very  severe  fall  on  his 
face  when  skating  on  the  ice  twenty  years  ago,  so  much  so  that 
he  had  considerably  injured  his  teeth,  and,  although  his  nose  was 
much  swollen  at  the  time,  he  was  unaware  that  it  had  been  per- 
manently injured  until  his  recent  discomfort  had  brought  the  past  to 
his  memory. 

This  case  was  also  treated  by  trephine  on  the  right  side,  and  tre- 
phine and  s'aw  on  the  left,  with  the  result  that  the  normal  breathway  was  completely 
re-established,  with  corresponding  disappearance  of  his  distressing  symptoms. 

Case  14. — J.  M.,  clerk,  age  31,  consulted  me  at  Easter,  1887,  on  account  of  hay-fever, 
paroxysmal  sneezing,  and  chronic  post-nasal  catarrh.  There 
was  no  history  of  any  previous  injury. 

He  was  the  subject  of  chronic  hypertrophic  rhinitis,  and 
an  irregular-spurred  deformity  of  the  septum,  partly  bony  and 
partly  cartilaginous,  and  more  pronounced  on  the  left  than 
on  the  right  side.  At  the  floor  of  the  right  inferior  meatus 
was  a  small  osteoma  arising  from  the  palatal  process  of 
the  maxilla,  to  the  importance  of  which  I  have  drawn 
attention.  Having  rectified  the  left  deviation  of  the  septum 
by  the  saw,  and  trephined  the  small  exostosis  on  the  right 
side,  cautery  was,  at  a  later  period,  applied  to  the  middle  and 
inferior  turbinals,  with  the  result  that  all  the  symptoms  of 
hay-fever  were  quite  relieved,  and  he  passed  the  following  summer  with  complete 
immunity  from  his  former  symptoms. 

Case  15  is  that  of  a  lady  of  title,  aged  about  26,  who,  inheriting  a  disposition  to  middle- 
ear  catarrh,  consulted  me  in  the  autumn  of  1887  on  account  of  increasing  deafness  and 
tinnitus,  with  muffled  voice,  dry  mouth  on  waking,  and  other  symptoms  of  impaired  nasal 
respiration.  On  examination  there  was  found  to  be  a  sigmoid- 
shaped  deviation  of  the  septum,  which  was  greatly  thickened, 
and  entirely  obstructed  the  middle  meatus,  and  partially  the 
inferior  of  the  left  side,  and  the  entire  inferior  meatus  of  the  right 
side. 

I  operated  on  the  left  nostril  by  trephine  and  saw,  in  November, 
1887,  assisted  by  Mr.  Jakins  and  Mr.  Braine,  administering 
chloroform.    The  only  after-disturbance  was  rather  severe  neur- 


FiG.  CCXIV. 


CCXV 


algia  ;  but  the  recovery  was  good,  and  improvement  on  that  side  so  complete  that 


6o5 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Fig.  CCXVI, 


in  the  spring  of  the  following  year  I  was  asked  to  operate  on  the  right  nostril.  This 
I  did  also  by  trephine  and  saw,  with  the  result  that  on  December  3,  1889,  I  received 
a  letter  from  her  mother,  saying  that  she  had  '  waited  a  little  while  to  observe  if  the 
improvement  in  her  daughter's  hearing  sustained  itself,  and  was  happy  to  report  that  it 
had  done  so,  and  had  been  remarked  upon  by  several  of  her  relations  while  visiting 
them.     This  case  is  known  also  to  Sir  Oscar  Clayton. 

This  lady  has  since  married,  and  continues  to  hold  the  improvement  I  was  able  to 
afford  her. 

Case  16. — Mr.  H.,  aet.  26,  an  officer  in  the  Royal  Engineers,  consulted  me  in  March, 
1888,  on  account  of  headache,  aprosexia  of  severe  grade,  dry  throat,  and  other  evidences 
of  nasal  obstruction.  Hearing  was  unimpaired,  but  an  almost  constant  tinnitus  was  com- 
plained of.  The  condition  was  attributed  to  an  injury  to  the 
nose  when  at  school. 

Anterior  rhinoscopic  examination  revealed  the  presence  of 
double-spurred  condition  of  the  septum  at  the  junction  of  the 
maxillary  crest  and  cartilage.  The  middle  and  inferior  turbinated 
bodies  were  hypertrophied  and  in  contact  with  the  septum,  the 
whole  causing  very  marked  stenosis. 

Under  the  influence  of  cocaine  the  left  spur  was  removed  by 
the  trephine,  the  right  with  a  saw.    Quoting  his  own  words  : 

'  Before  the  operation  I  had  no  pain  in  my  nose,  but  I  could 
not  breathe  through  the  left  nostril  at  all,  it  being  blocked  up  by 
a  hard  growth  of  some  sort.    My  breathing  through  the  other  nostril  was  only  partially 
impaired  by  the  same  cause. 

'  I  was  hardly  at  all  exhausted  after  the  operation — in  fact,  I  felt  quite  well  until  about 
two  or  three  days  afterwards,  when  I  got  a  little  headache,  owing  chiefly  to  lying  in  bed 
and  being  indoors,  I  think.  The  operation  itself  was  exceedingly  unpleasant,  but  after  it 
was  over  the  pain  I  suffered  was  very  slight  ;  but,  of  course,  the  discomfort  from  the 
plugs  which  were  inserted  was  very  great. 

'  My  operation  was  done  on  Monday.  On  Thursday,  I  think,  I  came  down  to  dinner, 
and  went  out  on  Saturday,  but  did  not  consider  myself  fit  to  do  as  usual,  i.e.,  take  any 
violent  exercise,  for  about  a  fortnight  more.  I  can  now  breathe  equally  well  through 
both  nostrils,  and  am  exceedingly  glad  I  had  the  operation  done.  I  also  used  to  have 
headaches,  and  a  dry  throat  on  awaking  in  the  morning,  both  of  which  have  now 
gone.' 

Case  17. — General  T.,  xt.  53,  retired  from  the  Royal  Engineers,  came  to  me  in  May, 
1888,  very  shortly  after  the  patient  whose  case  was  last  given;  and,  indeed,  the  letter 
quoted  was  in  response  to  inquiries  of  this  gentleman.  The  history  was  that  there  had 
been  a  serious  fall,  leading  to  a  broken  nose,  with  permanent 
external  disfigurement,  and  that  for  many  years  nasal  respiration 
had  been  almost  impossible,  so  that  sleep  had  been  most  disturbed 
and  discomfort  constant.  This  case  is  interesting  as  being  one  of 
the  few  I  have  seen  with  manifest  external  deformity  corresponding 
to  the  intra-nasal  mischief,  which  consisted  in  this  instance  of  a 
general  thickening  of  the  septum,  much  greater  on  the  left  and  right 
side,  the  deviation  being  evidently  the  result  of  traumatic  fracture. 

The  patient  was  operated  upon,  under  an  anesthetic  administered 
by  Mr.  Braine,  by  trephine  and  saw,  as  indicated  in  the  figure. 
Relief  was  immediate  ;  but  the  patient  had  to  leave  England  for 
Canada  before  he  was  really  well,  and  I  did  not  see  him  again  until  the  summer  of  1889, 
when  I  found  that  there  had  been  some  inflammatory  thickening,  leading  to  some  relapse 
of  the  symptoms.  I  destroyed  the  hypertrophic  tissue  by  cautery,  and  afterwards  enjoined 
the  introduction  of  nasal  bougies  with  iodol.  Under  this  treatment  the  nasal  breathway 
was  completely  and  permanently  re-established. 


Fig.  CCXVII. 


DEVIATIONS  AND  DEFORMITIES  OF  THE  SEPTUM.  607 


Case  18. — Mr.  G.  B,,  set.  43,  consulted  me  in  July,  1889, 
disturbed  sleep,  and  fulness  of  the  head.  I  found  a  very  con- 
gested pharynx,  and,  on  examination  of  the  nasal  fossre,  a  very 
considerable  hypertrophy  of  the  erectile  tissue  covering  the 
septum,  which  was,  however,  somewhat  reduced,  especially  on 
the  right  side,  by  application  of  cocaine.  The  patient  was  of 
gouty  habit  and  a  free  liver.  For  this  condition  he  was  treated 
for  some  days,  and  I  then  applied  the  galvano-cautery  to  the 
situation  of  the  overgrowth  on  two  successive  occasions,  a  week 
intervening  between  each.  He  was  further  treated  with  iodul 
ointment,  and  recommended  to  employ  a  menthol  inhaler. 
Under  these  measures  the  hypertrophy  was  reduced  and  the 
symptoms  almost  entirely  removed. 


on  account  of  snoring, 


Fig.  CCXVIII. 


Case  19. — Dr.  R.,  aet.  60,  consulted  me  in  1887  on  account  of  constant  irritation  in 
the  throat,  bronchitis  every  winter,  and  general  disposition  to  '  asthma '  without  any  actual 
attack  of  that  nature. 

On  examination  I  not  only  found  chronic  congestion  of 
the  pharyngeal  and  laryngeal  mucous  membrane,  but,  on 
anterior  rhinoscopy,  observed  that  he  was  the  subject  of  an 
enormously  thickened  and  deformed  septum,  the  deviation 
having  originally  been  of  a  sigmoid  character.  So  distorted 
were  the  parts  that  there  was  some  trouble  in  recognising  the 
respective  turbinals,  and  for  the  sake  of  elucidation  they  are 
indicated  by  letters  in  the  illustration.  With  the  probe  was 
felt  the  condition  described  by  Woakes  as  '  cleavage '  of 
the  middle  turbinal,  and  the  correctness  of  the  explanation 
given  of  this  phenomenon  at  page  609  was  very  clearly  made 
out. 

This  gentleman  derived  considerable  relief  from  treatment  of  his  pharyngeal  condition 
by  astringents,  and  the  soft  tissues  of  the  nares  were  reduced  by  means  of  menthol,  snuffs, 
and  inhalations,  and  by  iodol  ointment.  I  had  also  prescribed  chloride  of  ammonium  and 
iodide  of  sodium.    I  did  not  advise  operative  treatment. 

Case  20. — Mr.  M.  G.  C,  aged  18,  was  seen  by  me  on  June  18,  1888,  suffering  from 
toneless  voice,  headache,  deafness  in  the  left  ear,  and,  during  the  1 
last  month  or  two,  from  tinnitus.  On  questions  asked  it  was 
elicited  that  he  had  injured  his  nose  by  a  fall  from  his  pony 
when  between  four  and  live  years  of  age.  There  was  no  external 
deformity.  Anterior  rhinoscopy  showed  a  sigmoid  flexure  of  the 
septum,  with  a  large  enchondroma  blocking  the  left  nostril  an- 
teriorly. This  was  treated  by  saw  and  trephine,  and  the 
deviation  further  rectified  by  the  wearing  of  one  of  Grant's  splints 
when  the  parts  had  healed.  Politzer  inflation  was  also  employed 
to  improve  the  hearing,  and  in  the  end  an  entirely  successful  result  was  obtained. 


Fig.  CCXX. 


The  After-treatment  of  all  cases,  irrespective  of  the  exact  kind 
of  operation,  consists  in  plugging  with  absorbent  wool  medicated 
for  the  first  twenty-four  hours  with  a  strong  solution  of  pyoktanin, 
which  requires  some  care  in  introduction  so  as  not  to  stain  the 
external  nostril  more  than  possible  (the  stain  can  be  removed  by 
alcohol),  with  after  insufflations  of  aristol,  iodol,  or  sozo-iodol  for 
the  first  week,  and  later  an  iodol  ointment  twice  a  day,  by  means 


6o8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


of  a  brush,  or  a  solution  of  menthol  and  iodol  dissolved  in  olive 
oil  to  be  employed  as  a  spray. 

Douches  should  not  be  employed,  unless  there  is  haemorrhage, 
for  the  lirst  forty-eight  hours,  and  then  at  low  pressure.  My 
syringe  (Fig.  LXXIV.),  which  contains  only  two  ounces,  and  has 
several  points  of  exit  so  as  to  form  a  kind  of  coarse  spray,  is  both 
unobjectionable  and  effective.  I  generally  employ  a  solution  of  the 
alkaline  powder  (Form.  78) ,  or  Dobell's  solution  by  means  of  a  coarse 
spray.  The  mucous  membrane,  where  removed,  is  regenerated,  and 
the  wound  heals  usually  within  fourteen  days.  It  is  of  the  utmost 
importance  to  forewarn  a  patient  that  he  must  be  prepared  to  give 
up  so  much  time  for  rest  at  home  and  careful  surgical  nursing;  for 
while  it  is  difficult  to  over-estimate  the  amount  of  improvement 
to  be  gained  by  removal  of  septal  obstruction  in  suitable  cases, 
nothing  is  more  likely  to  bring  the  operation  into  disrepute  than 
an  under-estimation  of  the  mischief  which  might  occur  from  want 
of  care  during  convalescence. 

Dislocation  of  the  Columnar  Cartilage. — This  is  a  somewhat 
peculiar  deformity,  first  described  I  believe  by  Bosworth,  in  the 
following  words  :  *  We  find  lying  immediately  below  the  cartilage 
of  the  septum,  and  parallel  with  its  lower  border,  a  small  oblong 
plate  of  cartilage,  not  usually  mentioned  in  our  text-books  of 
anatomy,  the  purpose  of  which  seems  to  be  to  act  as  a  support 
for  the  integument  of  the  column.'  This  may  be  designated  as 
the  columnar  cartilage.  Bosworth  does  not  enter  into  the  ques- 
tion of  etiology,  though  he  suggests  that  in  one  of  the  two  cases 
he  relates,  *  the  cause  of  the  affection  was  the  pressure  of  the 
thumb  in  using  the  handkerchief.'  I  have  myself  seen  four  cases 
since  my  attention  was  drawn  to  the  subject. 

In  one,  a  young  lady  about  twenty-five,  it  was  attributed  to  severe  and  long-continued 
paroxysmal  sneezing,  but  there  was  also  pretty  constant  coryza,  so  that  Bosworth's 
explanation  might  have  obtained  in  this  case. 

The  second  and  third  were  a  boy,  aged  fifteen,  and  his  sister,  aged  thirteen,  brought  to 
me  by  Dr.  Forbes,  of  Eastwood.  The  first  had  suffered  two  severe  injuries  playing  foot- 
ball at  a  public  school  ;  the  young  lady  had  been  in  the  habit  of  descending  the  staircases 
by  the  balusters  instead  of  by  the  steps,  and  on  one  occasion  had  fallen  on  the  nose. 
Whether  these  injuries  were  causative  is  open  to  doubt,  since  the  father  had  a  similar 
deformity.  In  both  children  there  was  considerable  obstruction  to  nasal  breathing  from 
a  hypertrophied  pharyngeal  tonsil. 

Treatment  is  that  advised  by  Bosworth,  and  has  been  very 
successful  in  my  hands.  It  consists  in  dissecting  out  the  cartilage 
through  a  small  incision  made  over  it,  resecting  the  redundant 
portion  of  mucous  membrane,  and  uniting  the  edges  with  fine 
sutures. 


NECROSIS  AND  CARIES. 


609 


NECROSIS  AND  CARIES. 

Death  of  bone  or  cartilage  is  rare  except  in  connection  with 
certain  dyscrasiae,  which  are  separately  treated  in  these  pages, 
but  some  remarks  will  be  expected  regarding  the  condition  termed 
necrosing  ethmoiditis,  first  introduced  to  the  profession  by  Woakes 
some  ten  years  ago.  According  to  this  specialist  an  immense  number 
of  cases  of  necrosis  of  the  middle  turbinated  portion  of  the  ethmoid 
bone  are  seen  by  him  yearly,  and  in  very  frequent  association  with 
this  condition  are  found,  as  results,  polypi  and  polypoid  hyper- 
trophies, together  with  hay-fever,  asthma,  and  a  host  of  other 
neuroses  ;  most — -if  not  all — cases  of  polypi  have  been  said  by  him 
to  be  the  result  of  necrosis  of  the  middle  turbinated  bone.  Sur- 
gical removal  of  the  middle — or,  it  may  be,  the  inferior — turbinated 
body  is  the  treatment  recommended  and  carried  out  by  its  advocate. 
So  far  as  I  am  aware,  not  a  single  practitioner  of  any  experience,  at 
home  or  abroad,  has  been  able  to  confirm  Woakes'  observations,  at 
least  to  anything  like  so  great  an  extent  as  he  has  reported.  Necrosis 
of  the  ethmoid  bone  is  a  very  rare  affection,  and  is  usually  the  result 
of  syphilis;  but  cases  are  occasionally  seen  of  enlargement  of  the 
middle  turbinated  body  associated  with  polypi  or  polypoid  hyper- 
trophy of  the  mucous  membrane,  which,  when  tested  with  a  probe, 
give  the  characteristic  feeling  associated  with  the  probing  of  bones 
affected  with  osteitis  and  with  osteophytic  spicules  in  the  periosteal 
region.  This  rare  condition  may  in  some  instances  be  due  to 
ostitis  granulosa,  described  as  occurring  in  the  nose  only,  I  believe, 
by  MacDonald,  who,  however,  as  a  pupil  of  Woakes,  was  so  far 
from  being  impressed  with  the  frequency  of  '  necrosing  ethmoiditis 
in  almost  every  case  of  hyperplasia  involving  the  middle  turbinated 
tissue,'  that  he  is  perhaps  the  only  author  who  has  considered  the 
subject  worthy  of  serious,  though  condemnatory,  discussion.  The 
uneven  and  worm-eaten-like  surface  of  the  normal  turbinals — for 
the  support  of  the  cavernous  erectile  tissue — gives  a  sensation  to 
a  sharp  probe  very  like  carious  bone.  In  five  years  I  have  only 
seen  two  cases  which  could  be  described  as  caries  of  the  ethmoid 
bone  which  were  not  even  syphilitic  or  malignant.  From  in- 
quiries I  have  made  I  find  that  my  experience  is  in  accord  with 
that  of  every  rhinologist  of  note. 

Thus  I  wrote  in  my  last  edition,  and  since  then  the  subject  has 
received  further  notice. 

In  the  first  place,  a  paper  was  read  by  Dr.  Woakes  on  this 
subject  at  the  meeting  of  the  British  Medical  Association  in  July, 
i8gi,  supported  by  a  report  from  Dr.  Sidney  Martin  on  twenty 

39 


6ia  DISEASES  OF  THE  THROAT  AND  NOSE. 

different  specimens,  claimed  to  be  cases  of  the  disease ;  but  in' 
only  two  was  there  actual  necrosis  on  that  occasion,,  and  in  these 
in  '  the  absence  of  the  clinical  history  of  the  cases,  it  was  impos- 
sible to  say  to  what  the  necrosis  observed  in  the  two  specimens- 
was  due  ;  in  the  remaining  eighteen  specimens,  it  was,  however, 
a  definite  fact  that  no  necrosis  of  the  bone  was  present,  after  an 
exhaustive  examination  of  the  larger  pieces  of  the  ethmoid  he  had 
to  report  on,  Dr.  Sidney  Martin,  in  the  letter  above  quoted 
{Brit.  Med.  Journ.,  Dec.  24th,  1892),  fails  to  'see  in  what  way 
these  results  confirm  the  existence  of  ''  Necrosing  Ethmoiditis."  ' 

While  expressing  on  the  occasion  of  this  communication  of 
Dr.  Woakes,  the  highest  admiration  for  the  industry  and  per- 
severance displayed  by  the  author,  I  regretted  that  I  was 
unable  to  accept  his  conclusions,  but  ventured  to  say  that  nothing 
further  had  been  said  then,  beyond  what  Dr.  Woakes  had  been 
saying  for  six  or  seven  years,  to  convince  me  that  these  changes- 
were  due  to  necrosis  of  bone ;  and  if  necrosing  ethmoiditis — a 
term  which  was  applied  to  all  these  specimens — did  not  lead  to 
the  inference  that  they  were  all  the  subject  of  caries,  then  the- 
nomenclature  was  both  incorrect  and  misleading.  For  not  only 
were  the  analogies  that  Dr.  Woakes  drew  between  the  patho- 
logical  process  in  the  middle  turbinal,  and  that  in  a  carious  tooth 
or  astragalus  wanting  in  many  elements  for  correct  comparison,, 
but  clinical  evidence  entirely  fails  to  support  his  contention  as  tO' 
the  frequency,  and  indeed  universality,  of  necrosing  ethmoiditis 
in  every  case  of  nasal  myxoma. 

I  alluded  especially  to  the  clinical  element.  Two  signs  were 
conspicuous  by  their  absence  :  first,  the  stench  of  necrosed  bone 
is  most  rare  in  any  case  of  simple  polypus ;  and  secondly,  extru- 
sion of  necrosed  bone  is  unknown  even  in  patients  the  subject  of 
polypi  for  thirty  or  forty  3'ears.  I  did  not  say  that  necrosing 
ethmoiditis  never  existed,  but  in  my  experience,  as  in  that  of 
almost  all  other  rhinologists  except  Dr.  Woakes,  it  was  rare,  and 
was  invariably  the  result  of  a  specific  dyscrasia.  Dr.  W^oakes  in' 
reply  observed  that  the  term  necrosing  ethmoiditis  meant  an  in- 
flammation  of  the  ethmoid,  the  tendency  of  which  was  to  induce,  as- 
its  final  product,  necrosis  of  bone.  Obviously  this  implied  several" 
antecedent  stages  prior  to  the  arrival  at  necrosis — a  fact  which 
was  insisted  upon  in  Dr.  Woakes'  paper.  Of  these  antecedent 
stages,  the  first  was  fibrosis,  and  often — by  no  means  always — this- 
was  followed  by  the  presence  of  myxoma-polypus.  Usually  at  this 
period  there  was  no  necrosis,  but  not  the  less  surely  would  necrosis- 
appear  later  on,  if  the  disease  were  allowed  to  run  its  course.. 


NECROSIS  AND  CARIES. 


6ii 


To  my  observations  on  Dr.  Woakes'  contention  I  still  adhere, 
except  that  I  feel  bound,  in  justice  to  Dr.  Woakes,  to  withdraw  the 
statement  that  '  Necrosing  Ethmoiditis  is  "invariably  "  the  result 
of  a  specific  dyscrasia,'  for  it  is  probable  that  in  a  certain  proportion 
of  cases,  which,  however,  is  much  smaller  than  one  in  ten,  probably 
one  in  fifty  or  even  a  hundred,  a  condition  of  necrosis  does  exist 
which  is  not  due  to  specific  dyscrasia.  Dr.  Woakes'  remark  '  that 
the  term  "  necrosing  ethmoiditis  "  meant  an  inflammation  of  the 
ethmoid  bone,  the  tendency  of  which  was  to  induce,  as  its  final 
product,  necrosis  of  the  bone,'  merits  simply  the  reply  that  such 
an  interpretation  is  not  that  generally  received  when  the  word 
'  gangrenous  or  erysipelatous '  is  used  as  applied  to  an  inflamma- 
tion, nor  to  the  still  more  analogous  term  '  necrotic  '  or  '  carious ' 
degeneration  of  a  tissue  in  any  other  part  of  the  body. 

It  will  be  seen  from  the  foregoing  that  I  fully  recognise,  as  I 
believe  do  all  other  rhinologists,  that  Dr.  Woakes  has  detected 
and  correctly  described  a  certain  pathological  process  in  the 
ethmoid  bone  ;  and  it  is  probable  that  a  similar  process  occurs  in 
the  sinuses  of  the  frontal,  sphenoidal,  and  maxillary  bones ;  but 
he  has  failed  to  satisfactorily  demonstrate  that  necrosis  is  at  all  a 
frequent  result  of  this  process,  and  I  doubt  if  he  would  seriously 
make  such  a  claim,  for  necrosis  in  these  analogous  situations  would 
be  admitted  even  by  Dr.  Woakes  himself  to  be  extremely  rare,  albeit 
that  certain  polypoid  growths  are  very  frequently  to  be  found  in  con- 
nection with  empyema  of  both  the  maxillary  and  the  frontal  antra, 
and  these  new  formations  are  found  alike  in  both  hypertrophic  and 
atrophic  changes  of  the  turbinals,  the  former,  however,  being  the 
most  frequent.  It  is  to  be  hoped  therefore  that  a  compromise 
may  soon  be  arrived  at,  for  I  feel  convinced  there  is  a  general 
tendency  to  admit  that,  if  Dr.  Woakes  would  withdraw  the  term 
'  necrosing,'  as  at  all  distinctive  or  characteristic  of  ethmoiditis, 
his  views  would  obtain  that  large  share  of  recognition  to  which 
they  are  on  all  other  grounds  entitled. 

Treatment. — The  very  rare  cases  in  which  true  necrosis  is 
found,  especially  if  in  association  with  polypi,  are  best  treated  by 
curetting  the  necrosing  area  with  a  spoon-shaped  instrument,  and 
then  packing  with  iodol.  Should  this  prove  ineffectual,  a  larger  or 
smaller  portion  can  be  removed  by  nasal  bone  forceps,  or  by  the 
snare.  I  am  not  an  advocate  for  removing  the  middle  turbinal 
body  in  its  entirety. 

W^oakes  has  also  described  '  cleavage  '  of  the  middle  turbinated 
body,  and  has  figured  such  a  condition  in  his  work  as  one  of  the 
attendant  phenomena  of  the  'necrosing'  process;  but  the  appear- 


6l2 


DISEASES  OF  THE  THROAT  AND  NOSE. 


ance  of  '  two  vertical  sausage-shaped  bodies/  with  a  cleft  between 
them,  situated  in  the  middle  turbinated  area,  is  not  really  cleavage 
of  the  turbinal ;  for  the  inner  of  the  two  vertical  bodies  is  the 
middle  turbinal  itself,  and  the  outer  body  the  prominent  and 
hypertrophied  bulla  ethmoidalis.  This  interpretation  of  appear- 
ances exceptionally  to  be  observed,  which  was  originally  supplied 
to  me  by  Dundas  Grant  some  years  ago,  is,  I  think,  undoubtedly 
the  correct  one,  and  may  be  independently  confirmed  by  anyone 
on  inspection  and  probing.  In  corroboration  thereof  it  may, 
moreover,  be  mentioned  that  post-mortem  evidence  of  a  cleft 
middle  turbinal  is  altogether  wanting. 

Synostosis  is  a  term  I  apply  to  a  bony  or  cartilaginous  bridge 
which  one  occasionally  sees  extending  from  the  bony  septum  to 
either  the  middle  or  inferior  turbinal  as  a  product  of  non-trau- 
miatic  inflammation,  and  sometimes  as  an  untoward  result  of 
cauterization  or  other  intra-nasal  operations,  in  which  directions 
for  further  dilatation  by  means  of  bougies  or  hollow  nasal  tubes 
have  been  neglected.  When  these  adhesions  cause  obstruction, 
their  removal  by  saw,  trephine,  etc.,  followed  by  careful  dilatation, 
is  the  treatment  obviously  indicated. 

III.    NEW  GROWTHS,   WHETHER   OF  MUCOUS 
MEMBRANE,  BONE,  OR  CARTILAGE. 

NASAL  POLYPI,  AND  OTHER  BENIGN  GROWTHS. 

These  growths  are  of  two  kinds,  the  myxomata  and  fibro- 
mata ;  for  the  sake  of  convenience  other  benign  growths  of  the 
nares  will  be  included  in  this  section.  Fibromata  are,  however, 
very  rare,  and  moreover  present  symptoms  and  considerations 
for  treatment  of  such  an  entirely  different  character,  that  the 
term  polypus  should,  clinically  speaking,  be  restricted  to  innocent 
mucous  pedunculated  growths.  The  word  polypus  is  derived 
from  the  fancied  resemblance  to  a  zoophite,  and  the  appearance  in 
the  nostril  has  been  compared  to  that  of  an  oyster  ;  also,  on  account 
of  its  translucency,  to  the  pulp  of  a  grape. 

According  to  Zuckerkandl,  in  nearly  half  the  cases  examined  by 
him  post-mortem,  the  growths  sprang  from  the  mucous  membrane 
bounding  the  hiatus  semilunaris ;  and  it  is  probable  that  in  more 
than  four-fifths  of  the  cases  they  arise  from,  or  near  to,  the  middle 
turbinated  body  and  bulla  ethmoidalis.  They  are  not  infrequently 
present  in  the  accessory  cavities,  notably  that  of  the  antrum. 
Although  reported  to  be  rare  on  the  superior  turbinated  body  and 


NASAL  POLYPI,  AND  OTHER  BENIGN  GROWTHS.  613 


roof,  I  almost  weekly  remove  small  growths,  which  apparently 
arise  above  the  middle  turbinal,  and  therefore  presumably  from 
one  of  these  upper  sites.  It  is  doubtful  if  true  polypi  ever  arise 
from  the  septum,  and  in  the  few  cases  in  which  septal  growths 
have  been  reported,  they  w^ere  probably,  as  in  one  observed  by 
myself,  of  a  warty  (papillomatous)  nature. 

Growths  of  the  inferior  turbinated  body  rarely  have  slender 
peduncles  ;  they  have  been  already  alluded  to  as  moriform  polypoid 
excrescences  under  the  head  of  hypertrophic  rhinitis,  which  they 
often  complicate.  They  are,  in  my  experience,  seldom  seen  in 
conjunction  with  ordinary  polypi,  and  are  rather  of  the  nature  of 
angiomata,  the  condition  already  described  as  turbinal  varix. 

Although  polypi  usually  commences  in  one  nostril,  their  pre- 
sence in  both  is  the  rule  in  well-established  cases.  This  fact  wall, 
however,  be  only  demonstrated  on  visual  examination.  Or  per- 
haps the  patient  may  complain  only  of  unilateral  obstruction  in 
the  first  instance,  and  will  not  be  conscious  of  disease  in  the 
opposite  nostril  until  that  in  the  first  has  been  removed.  Not- 
withstanding that  polyps,  when  developed  to  moderate  size,  are 
always  pedunculated,  they  most  likely,  as  already  pointed  out, 
arise  as  sessile  oedematous  swellings  at  dependent  situations.  I 
believe  that  this  lymphatic  oedema  is  usually  the  result  of  chronic 
catarrh,  often  hypertrophic  in  character,  and  in  some  instances 
complicated  by  obstructive  septal  spurs  and  deflections.  Bos- 
worth  happily  describes  the  mucous  covering  of  the  middle 
turbinal  area  in  this  condition  as  becoming  '  water-soaked,'  and 
teaches  that  subsequent  pyriform  growth  is  accounted  for  by 
anterior  stenosis  and  suction  action  in  hav^'king,  sniffing,  and  nose- 
blowing  efforts,  while,  as  I  have  already  remarked,  pedunculation 
may  be  due  simply  to  the  force  of  gravity. 

Morell  Mackenzie  hesitates  to  accept  catarrh  as  an  important 
etiological  factor  on  the  ground  that  whereas  polypi  are  rare 
before  puberty,  catarrh  is  common  enough  in  early  years.  It 
must  be  remembered,  however,  that  though  profuse  muco- 
purulent catarrh  is  common  in  children,  true  hypertrophic  rhinitis 
and  septal  deviations,  both  of  which  lead  to  thickening  of  the 
epithelial  and  other  layers  and  to  diminished  w^atery  secretion, 
are  decidedly  rare  in  early  life — at  least,  such  is  my  experience, 
and  is  indeed  logically  conclusive,  since  not  till  puberty  are  the 
turbinals  fully  developed.  Nasal  polypi  are  more  frequent  in  the 
male  sex,  and  may  occur  at  almost  any  age.  I  have  operated  on 
patients  as  young  as  seven,  and  on  one  as  old  as  eighty.  The 
majority  of  my  patients  have  been  over  thirty  years  of  age. 


6i4 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Pathology.  —  Mucous  polypi  are  generally  covered  with 
columnar  ciliated  epithelium,  so  long  as  the  growths  lie  simply 
flopping  about  in  the  choanse,  but  when  projecting  out  of  them 
anteriorly  or  posteriorly,  the  epithelium  becomes  much  thickened 
— probably  by  friction — and  assumes  a  stratified  structure.  The 
substance  of  the  growth  in  such  circumstances  becomes  more  solid. 

An  ordinary  polypus  is  composed  of  myxomatous  or  embryonic 
connective-tissue,  with  stellate  cells  and  a  large  amount  of  inter- 
cellular substance  containing  much  mucin.  The  amount  of 
tubular  gland-tissue  present  varies  considerably  ;  this  may  become 
atrophied  or  hypertrophied,  and  thus  give  to  the  polypus  an 
adenomatous  structure,  or  more  rarely  the  glands  give  rise  to 
small  and  even  large  cysts.    Cystic  degeneration  is  also  sometimes 


Fig.  CCXXI.— Mucous  Polypus  of  the  Nose. — This  drawing  of  a  polypus,  taken 
intact  from  the  left  nostril  of  a  young  lady,  xt.  24,  by  means  of  a  wire  loop  passed 
from  behind  the  soft  palate,  fairly  well  indicates  the  firmer  myxo-fibromatous 
character  of  the  growth,  with  ulceration  of  the  portions  (P)  presenting  at  the  back  of 
the  throat,  and  the  friably  mucous  form  of  that  (A)  which  had  lain  comparatively 
quiescent  in  the  choanse,  and  was  visible  by  anterior  rhinoscopy. 

said  to  be  due  to  liquefacti'on  of  the  myxomatous  tissue.  Nerves 
are  not  easily  demonstrable,  and  the  vessels  are  sparse  except  at 
the  peduncle,  where  doubtless  the  veins  and  lymphatics  are  more 
or  less  strangulated.  The  preponderance  of  afferent  over  efferent 
vessels  explains  the  rapidity  and  excessive  serosity  of  the  growth. 
It  also  accounts  for  excessive  haemorrhage  on  incomplete  removal, 
and  the  tendency  to  recurrence  unless  the  peduncular  attachment 
is  obliterated. 

Symptoms. — The  prominent  symptom  of  polypus  is  partial  or 
complete  nasal  stenosis,  according  as  the  obstruction  is  confined 


NASAL  POLYPI,  AND  OTHER  BENIGN  GROWTHS.  615 

ito  the  middle  meatus  or  invades  the  inferior  also.  These 
symptoms  are  generally,  but  not  always,  bilateral.    Stenosis  will 

•  depend  on  the  amount  of  accompanying  alar  collapse,  turbinal 
hypertrophy,  and  septal  deformity  ;  it  will  vary  according  to  the 
.amount  of  moisture  in  the  atmosphere.  Bosworth  actually 
doubts  the  hygroscopic  properties  of  polypi.  Macdonald's  ex- 
periments, however,  amply  confirm  the  time-honoured  evidence 
of  daily  clinical  experience.  Stuffiness  is  sometimes  accom- 
panied by  the  feeling  of  a  moving  body  in  the  nose.  Sneezing  is, 
in  my  experience,  non-constant,  and  indeed  infrequent,  though 
Bosworth  holds  that  it  is  par  excellence  the  symptom  of  polypus. 
Sneezing,  when  present,  cannot  be  due  to  any  acuteness  of  sensa- 
tion on  the  part  of  the  polypus,  but  must  be  ascribed  to  hyper- 
■  sesthesia  of  the  'sensitive  areas'  of  the  mucosa  proper. 

Excessive  secretion  from  the  rest  of  the  mucous  membrane,  due 
to  the  stimulus  of  the  polypus  acting  as  a  foreign  body,  is  often 
marked.  A  purulent  discharge  generally  indicates,  I  think, 
partial  obstruction  of  the  orifices  of  the  accessory  sinuses,  which, 
if  malodorous,  further  points  to  retention  and  decomposition. 
There  is  then  occasionally  a  feeling  of  fulness  of  the  sinuses. 
;Lachrymation  ensues  when  the  nasal  duct  is  pressed  on  or 
lobstructed  either  directly  or  from  concomitant  catarrh.  Mucous 
polypi  never  cause  marked  displacement  of  bones,  though  the 
bridge  of  the  nose  often  appears  widened,  and  pressure  on  the 
veins  causes  oedema  at  the  root  of  the  nose,  with  fulness  of  the 
vessels  of  the  orbit  and  cranium. 

Voltolini  was  one  of  the  first  to  connect  asthma  and  other 
reflex  neuroses  with  the  presence  of  nasal  polypi.  Headache  and 
aprosexia  are  frequent.  Any  or  all  of  the  functions  of  smell, 
taste,  hearing,  voice-production,  and  even  sight,  may  be  impaired, 
the  rationale  of  which  results  have  been  already  explained  in  the 
previous  chapter.  Pharyngitis,  laryngitis,  and  bronchitis  often 
constitute  later  complications  of  fully  established  mouth-breathing. 
The  peculiar  toneless,  muffled  voice  and  thick  articulation  are  so 

•  characteristic  as  to  give  the  lead  to  correct  diagnosis  on  the  first 
\words  of  the  patient. 

Diagnosis  is  easy  on  account  of  the  position,  colour,  shape, 
>and  mobility  of  the  growths,  as  tested  by  inspection  and  probing. 
Fibromata  are  hard,  sessile,  and  readily  bleed.  Mucous  polypi 
.cannot,  with  care,  be  mistaken  for  mere  turbinal  hypertrophy,  or 
such  rare  growths  as  osteomata  and  enchondromata,  or  for  a  spur, 
.abscess,  or  hsematoma  of  the  septum.  It  would  be  a  serious 
blunder  to  diagnose  a  polypus  for  a  meningocele. 


6i6 


DISEASES  OF  THE  THRO  AT  AND  NOSE. 


Prognosis. — There  is  no  danger  to  life  except  in  those  rare 
instances  in  which  polyps  undergo  sarcomatous  or  carcinomatous 
changes.  Such  an  event  has  been  stated  to  be  the  result  of 
repeated  operation  for  recurrence,  but  I  have  never  had  or  seen  a 
case  in  which  the  evidence  was  at  all  conclusive  of  such  an 
hypothesis.  The  inference  that  it  would  be  more  probable  to 
follow  on  crude  and  rough  attempts  at  evulsion  is  certainly  not 
without  the  justification  of  experience.  The  tendency,  however, 
is  for  all  these  growths  to  become  more  and  more  fibrous  each 
time  they  reappear,  constituting  the  myxofibroma  of  some 
authors.  The  result  of  treatment  as  regards  the  relief  of 
symptoms,  including  the  impairment  of  the  special  senses,  is 
nearly  always  favourable.  Hearing  is  generally  improved,  and 
further  impairment  prevented. 

Asthma,  in  association  wdth  nasal  polypi,  is  in  a  large  number 
of  cases  absolutely  cured  by  removal  of  the  growths  ;  but  such  a 
fortunate  result  cannot  always  be  promised,  and  I  know  of  no 
method  which  will  enable  one  to  give  a  differential  prognosti- 
cation on  this  head.  Presumably  those  cases  in  which  a  reflex 
asthma  had  longest  existed  would  be  those  in  which  failure  might 
be  anticipated,  on  account  of  the  long-standing  cause,  but  I  could 
quote  many  cases  in  opposition  to  this  d  priori  deduction,  as  well 
as  some  in  its  support. 

Regarding  recurrence,  I  am  careful  to  insist  on  the  importance 
of  immediate  attention  on  the  part  of  the  patient  to  the  slightest 
reappearance  of  symptoms,  and  on  the  removal  of  any  new 
growth,  however  small,  so  soon  as  discovered.  It  is  only  by  such 
co-operation  of  attention  and  perseverance  on  the  part  of  surgeon 
and  patient  that  hope  of  a  radical  cure  can  be  promised  with  any 
degree  of  certainty. 

Treatment. — No  doubt  powders  of  alum  or  tannin  temporarily 
reduce  the  size  of  polyps,  and  somewhat  relieve  nasal  obstruction 
by  depriving  the  polypi  of  some  of  their  water,  but  such  treat- 
ment has  no  other  than  a  temporary  anti-hygroscopic  action. 
Caustic  powders,  used  as  snuffs,  are,  to  say  the  least,  dangerous. 
Caustic  pastes  or  solutions,  applied  scciindcni  artcin  to  the  base  of 
a  polypus  when  it  can  be  clearly  made  out  under  proper  rhino- 
scopic  illumination,  might  be  fairly  safe  in  the  hands  of  experts, 
who,  however,  usually  select  other  means ;  but  such  measures 
are  but  too  often  blindly  attempted  by  those  unskilled  in  intra- 
nasal manipulations,  with,  it  may  be,  the  result  of  great  ulcerative 
destruction  of  the  olfactory  and  respiratory  mucous  membrane 
and  only  partial  eradication  of  the  growths.    For  this  purpose 


NASAL  POLYPI,  AND  OTHER  BENIGN  GROWTHS. 


617 


chloride  of  iron,  bichromate  of  potash,  chloride  of  zinc,  nitrate  of 
silver,  chromic  and  carbolic  acids,  have  been  from  time  to  time 
recommended.    Such  methods  I  unhesitatingly  condemn. 

Much  discussion  has  taken  place  over  the  time-honoured 
method  of  evulsion  by  forceps  ;  here,  again,  much  harm  has  over 
and  over  again  been  done  to  the  inferior  turbinated  bodies,  the 
ethmoid  bone,  septum,  accessory  sinuses,  and  nasal  duct.  With 
a  proper  rhinoscopic  examination  and  competent  manipulation, 
such  culpable  accidents  never  occur.  The  growth  is  grasped  as 
near  as  possible  to  the  base,  and  forcibly  torn  or  tv^isted  from  its 
attachments.  By  this  method  it  sometimes  happens  that  a  por- 
tion of  the  ethmoid  bone  is  removed  along  with  the  growth. 
While  I  agree  with  Bosworth  in  his  dissent  from  Morell  Mackenzie's 
statement  that  such  removal  '  is  not  only  justifiable,  but  often- 
times demanded,'  I  do  not  consider  that  the  circumstance  is  to  be 
regarded  as  an  accident  of  import,  nor  can  I  endorse  Bosworth's 
objection  on  the  ground  that  '  the  origin  of  the  tumour  is  not  in 
the  bone,  but  in  the  mucous  membrane,'  for  without  doubt  it  does 
frequently  involve  the  periosteum. 

Provided  good  illumination  is  employed,  and  the  eye  guides  the 
instrument,  it  is  immaterial  whether  snares  (Figs.  XCVI.  and 
XCVII.)  or  forceps  (Figs.  XCVIII.  and  XCIX.,  p.  140)  be  intro- 
duced. I  myself  now  rarely  use  any  other  instrument  than  the 
cold  wire  snare,  with  forceps  as  an  occasional  adjuvant. 

Some  years  ago  I  made  a  long-continued  trial  of  the  galvano- 
cautery  snare-loop  for  removal  of  nasal  polypi ;  but  I  came  to  the 
conclusion  that  the  platinum  wire  required  for  this  purpose  was 
far  less  adaptable  than  the  steel  wire  of  the  cold  snare  :  also  it  was 
necessary  to  employ  special  hooks  for  securing  the  growth  while 
the  loop  was  adjusted  (Fig.  XCV.,  p.  139).  It  is  true  that  steel 
loops  are  now  used  for  cautery  instead  of  platinum,  but  as  they 
lose  their  temper  and  rigidity  after  once  being  heated  to  redness, 
the  instrument  has  to  be  re-charged  for  each  separate  introduc- 
tion— an  altogether  needless  waste  of  time  and  trouble — for  the 
vaunted  superiority  in  regard  to  diminished  pain,  and  especially 
diminished  haemorrhage,  of  the  cautery  over  the  cold  steel  loop 
has  not  been  borne  out  in  my  experience. 

Morell  Mackenzie  lauds  the  ordinary  galvano-caustic  electrode 
used  as  a  knife  to  cut  through  the  pedicles.  Such  a  method 
should  be  used  with  great  caution  in  the  upper  meatus,  even  by 
an  expert. 

Prior  to  all  operations  at  removal,  cocaine  should  be  employed, 
as  recommended  in  the  section  on  anaesthetics,  page  145. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Haemorrhage,  although  free  at  the  time  of  operation  with  snare 
or  forceps,  is  but  seldom  alarming,  and  decreases  in  proportion  as 
the  eradication  is  complete.  It  can  generally  be  stopped  by  appli- 
cation of  cocaine  or  antipyrin,  in  lo  to  20  per  cent,  solutions,  on 
cotton-wool,  or  by  a  hot-water  douche.  I  have  observed  that  in 
those  cases  in  which  after-bleeding  occurs  to  such  an  extent  as  to 
necessitate  posterior  plugging  of  the  nostrils,  the  putrefactive 
changes  which  almost  invariably  follow,  greatly  reduce  the 
chances  of  recurrence  of  the  growth. 

The  main  point  for  the  cure  of  polypus  consists  not  so  much  in 
the  removal  of  the  growth — nor,  indeed,  in  the  all-important 
complete  eradication  of  the  minutest  visible  polypus — as  in  the 
destruction  of  the  soil  and  the  bases  of  their  origin,  and  in  the 
cure  of  the  catarrh,  which,  while  an  almost  constant  first  cause, 
is  also  very  frequently  an  obstinate  sequel.  So  long  as  this 
catarrh  exists,  the  fear  of  recurrence  must  always  be  present  ; 
and  it  is  here  that  the  value  of  the  galvano-cautery  is  manifested 
as  pre-eminent  above  all  other  forms  of  local  treatment.  It  is 
my  custom,  long  after  every  sign  of  polypus  has  been  removed,  to 
make  weekly,  or  less  frequent  searings  of  limited  and  indicated 
portions  of  the  mucous  membrane  with  the  cautery-point,  until 
the  secreting  surface  is  so  changed  that  the  flux  becomes  arrested. 

Other  assistant  measures,  as  the  use  of  vaseline  ointments  or 
sprays  medicated  with  iodol,  menthol,  or  eucalyptol ;  constitu- 
tional medicines,  such  as  arsenic,  belladonna  and  phosphorus, 
Turkish  baths,  the  waters  of  Aix-les-Bains,  Challes,  and  Mont 
Dore  ;  of  mountain  air,  sea-voyages,  and  the  like,  are  all  of  advan- 
tage in  confirming  a  cure.  I  have  largely  ceased  to  employ  douches 
at  any  stage  of  a  nasal  disease  occurring  in  the  subject  of  polypus. 

Polypoid  excrescences  and  hypertrophies  of  the  posterior 
surfaces  of  the  inferior  turbinated  body  may  be  removed  by 
Hamilton's  instrument  (Fig.  XCVII.,  p.  140),  or  a  somewhat 
similar  one  known  as  Jarvis's ;  or  by  the  '  spoke  shave '  of  my 
•colleague,  Carmalt  Jones,  who  has  attained  very  brilliant  results 
by  its  employment. 

FIBROMATA. 

Bosworth  has  hunted  up  forty-one  cases  of  this  rare  disease. 
The  growths  are  of  the  same  typical  structure  as  those  occurring 
in  the  uterus  and  elsewhere,  and  are  said  to  originate  from  the 
nerve-sheaths.  They  differ  from  mucous  polypi  in  colour,  con- 
sistence to  the  probe,  in  the  absence  of  peduncle — for  they  are 
usually  sessile — and  in  their  often  lobulated  and  irregular  appear- 


CYSTOMA  TA. 


619 


ance.  These  points  will  be  evident  on  combined  anterior  and 
posterior  rhinoscopic  examination.  Their  presence  is  associated 
with  frequent  and  often  grave  epistaxis,  and  there  is  generally  a 
profuse  discharge  of  muco-pus.  In  addition  to  nasal  stenosis,  with 
the  usual  accompanying  symptoms  of  obstruction,  they  sooner  or 
later  lead  to  the  external  deformity  of  the  nose  known  as  '  frog- 
face,'  due  to  expansion  of  the  nasal  bones  ;  they  exhibit  the  most 
-unrelenting  progress  in  their  growth,  causing  absorption  of  bone 
and  other  tissues,  and  encroaching  on  the  pharynx,  antrum,  orbit, 
and  cranial  cavity.  If  untreated,  they  destroy  life  by  means  of  this 
extension  and  from  repeated  haemorrhage.  On  the  other  hand, 
apart  from  doing  harm  by  pressure  due  to  increase  of  growth,  they 
>are  not  malignant  in  the  true  sense. 

Treatment. — If  recognised  at  an  early  stage,  a  permanent  cure 
may  be  effected  by  means  of  the  snare  or  galvano-cautery, 
•operating  through  the  ordinary  channels  ;  but  when  once  they 
have  attained  sufficient  size  to  encroach  on  neighbouring  areas, 
some  such  more  formidable  external  operation  as  Rouge^s  or 
Ollier's,  at  the  hands  of  the  general  operating  surgeon,  will  be 
necessary.  The  prognosis  is  usually  favourable,  haemorrhage 
being  the  most  dangerous  complication. 

[For  details  of  the  external  nasal  operations,  the  student  is 
referred  to  Bosworth's  work,  and  to  the  larger  Systems  and 
Dictionaries  of  Surgery.] 

CYSTOMATA. 

Cystic  growths  are  only  rarely  met  with  in  the  nasal  choanse. 
They  usually  look  exactly  like  mucous  polypi,  and  their  true 
nature  is  often  shown  by  their  collapsing  when  examined 
digitally,  as  is  the  case  of  those  growing  from  the  posterior 
•extremities  of  the  turbinals,  or  on  seizure  by  forceps  or  snare. 
Occasionally,  as  mentioned  in  the  section  on  Mucous  Polypi, 
those  structures  undergo  cystic  degeneration.  After  evacuation 
of  their  colourless  or  slightly  reddish  viscid  fluid,  cysts  do  not 
^often  recur.  When  they  spring  from  the  anterior  extremity  of  the 
inferior  turbinated  body,  simple  incision  may  effect  a  cure. 

I  have  seen  but  two  cases  of  this  nature  : 

Case  i  occurred  to  me  in  1872  in  the  person  of  a  lady,  aged  36,  who  had  long  suffered 
'from  nasal  discomfort,  the  cause  for  which  had  apparently  not  been  discovered.  Indeed, 
Iher  nostrils  had  never  been  examined.  Observing  a  glistening  body  in  the  upper  part  of 
the  right  middle  meatus,  I  applied  a  snare  in  the  belief  that  it  was  a  polypus.  In  tightening 
the  loop,  the  growth  collapsed,  a  rush  of  clear  fluid  came  from  the  nostril,  and  only  a 
-Bhred  of  membrane  representing  the  capsule  of  the  cyst  was  withdrawn  by  the  instrument. 


620 


DISEASES  OF  THE  THROAT  AND  NOSE. 


I  applied  galvano-cautery  to  the  site  of  attachment,  and  the  patient  was  effectually  and 
permanently  cured. 

Case  2  is  that  of  a  young  lady  of  half-caste  African  birth,  aged  about  25,  who  suffers 
from  obstruction  of  the  left  nostril,  on  account  of  a  soft  cystic  growth  attached  to  the 
posterior  part  of  the  corresponding  turbinated  body.  Frequent  operations  with  the  snare 
have  resulted  in  detaching  shreds  of  membrane,  and  the  release  of  some  glairy  fluid  ;  but 
recurrence  has  always  taken  place.  I  have,  therefore,  recently  treated  with  the  galvano- 
cautery,  with  the  effect  of  giving  permanent  relief. 

PAPILLOMATA. 

Warty  growths  exhibiting  under  the  microscope  typical  papil- 
lary structure,  are  occasionally  seen  springing  from  the  septum 
or  inferior  turbinated  bodies  in  young  persons  about  the  age 
of  puberty.  They  sometimes  grow  from  the  lining  of  the 
vestibule.  According  to  Hopmann,  twenty  per  cent,  of  cases 
roughly  diagnosed  as  polypi  are  really  of  a  papillomatous  nature, 
but  this  is  doubtful,  for  such  frequency  of  occurrence  has  not  been 
observed  in  the  practice  of  others.  Warts  are  easily  snared,  and 
the  bases  should  be  destroyed  by  chemical  or  galvanic  cautery. 

Enchondromata. — This  term  it  is  convenient  to  restrict  to  all 
cartilaginous  tumours  springing  from  any  part  of  the  nasal 
cavities  or  accessory  sinuses,  other  than  the  septum.  Enchondroses 
of  the  triangular  cartilage  have  been  already  fully  discussed  as 
septal  cartilaginous  spurs.  They  cause  stenosis  of  the  choanae, 
but  do  not  displace  the  bony  framework  of  the  nose  by  excessive 
growth,  which,  on  the  other  hand,  is  often  characteristic  of 
enchondromata.  These  growths  are  frequently  the  occasion  of 
considerable  nasal  deformity,  and  may  even  lead  to  osseous 
absorption,  and,  by  pressure,  cause  destruction  in  the  orbit 
or  cranium.  In  addition  they  may  give  rise  to  any  or  all  of 
the  symptoms  of  nasal  obstruction.  They  not  unfrequently 
undergo  degeneration  of  a  semi-malignant  sarcomatous  type.  If 
detected  early  they  can  be  removed  with  the  nasal  drill  or 
trephine,  worked  by  a  surgical  engine  or  electro-motor.  When 
large  enough  to  cause  deformity  or  pressure  on  neighbouring  parts 
an  external  operation  will  be  necessary.  (See  note  to  Fibromata.) 

Osteomata,  or  bony  tumours,  are  of  rare  occurrence  in  the 
nose.  They  are  said  to  spring  from  the  mucous  membrane  of 
the  nares,  or  from  the  accessory  cavities.  They  are  usually 
pedunculated,  and,  in  addition  to  more  or  less  evident  symptoms 
of  obstruction,  they  give  rise  to  headache,  epistaxis,  and  a  muco- 
purulent discharge.  They  can  be  removed,  when  accessible,  by 
forceps,  snare,  or  saw. 

Exostoses — outgrowths  of  the  bony  framework — have  been 


MALIGNANT  GROWTHS. 


621 


already  alluded  to  in  the  section  on  deviations  and  spurs  of  the 
bony  septum  ;  in  addition  I  occasionally  meet  with  them  ante- 
riorly in  the  inferior  meat'us,  as  pedunculated  or  as  pyramidal 
growths  springing  from  the  maxillary  crest,  or  from  the  floor  of 
the  nasal  fossae,  where  they  cause  anterior  stenosis.  In  this 
situation  they  may  be  the  unrecognised  cause  of  a  stenosis,  or  the 
reason  for  an  incomplete  relief  in  cases  in  which  septal  deviations 
have  been  corrected.  They  can  be  easily  and  safely  removed  by 
the  nasal  saw,  drill,  or  trephine. 

MALIGNANT  GROWTHS. 

Sarcomata  sometimes  originate  in  the  nasal  fossse,  or  they  may 
invade  them  from  adjacent  structures.  The  septum  and  the 
antral  partition  are  apparently  the  commonest  sites,  though  I  can 
call  to  mind  cases  in  w^hich  sarcomatous  growths  have  been 
removed  by  me  from  the  superior  meatus  under  the  impression 
that  they  were  innocent,  until  rapid  recurrence  led  to  a  micro- 
scopical examination.  Allusion  has  already  been  made  to  the 
■exceptional  sarcomatous  or  carcinomatous  degeneration  of  myxo- 
mata,  fibromata,  and  enchondromata. 

Nasal  sarcomata  usually  present  round,  fusiform,  and  myeloid 
■cells,  one  or  other  of  these,  however,  predominating.  These 
growths  increase  rapidly  in  children,  but  often  more  slowly  in 
adults  ;  they  have  a  fleshy  appearance,  and  are  red  or  violet 
in  colour,  and  they  generally  give  rise  to  a  bloody,  foetid  discharge. 
When  the  symptoms  of  nasal  obstruction  supervene,  pain  becomes 
prominent,  which  is  increased  when  the  tumour  invades  or  expands 
neighbouring  areas.  In  such  circumstances  deformity  is  a  natural 
consequence. 

Treatment. — If  the  growth  is  high  up  and  not  rapidly  grow- 
ing, the  less  it  is  interfered  with  the  better.  When  in  the  lower 
choanae,  and  provided  that  the  case  is  seen  before  the  growth  has 
attained  a  large  size,  some  form  of  external  operation  (Ollier's, 
Rouge's,  etc.)  may  be  attempted.  Palliative  anodyne  sprays, 
containing  belladonna,  morphia,  or  cocaine,  are  useful  in  relieving 
pain.    Mild  astringents  do  no  harm. 

Carcinomata. — Primary  nasal  cancer  is  a  rare  condition.  In 
children  it  is  of  the  epithelial  or  of  the  encephaloid  variety. 
Scirrhus  most  exceptionally  occurs  in  middle-aged  persons. 
Cancer  by  invasion  from  neighbouring  parts  is  more  common. 
The  symptoms  are  very  like  those  of  sarcomata,  except  that 
there  is  a  greater  tendency  to  ulceration  and  haemorrhage,  and 
i:he  neighbouring  glands   become  accordingly  involved.  The 


622 


DISEASES  OF  THE  THROAT  AND  NOSE. 


remarks  on  treatment  under  the  heading  of  Sarcomata  apply 
here.  I  have  never  advised  operations  myself,  nor  would  I  perform 
them,  preferring  that  the  patients  take  the  benefit  of  the  opinion 
of  a  general  surgeon  experienced  in  such  cases. 

IV.    EPISTAXIS,  OR  RHINORRHAGIA. 

Sir  Thomas  Watson  has  pithily  observed  that  nose-bleeding  is 
*  sometimes  a  remedy,  sometimes  a  warning,  sometimes  really  a 
disease  in  itself.' 

Epistaxis  in  connection  with  operations  on  the  nose  is  rarely 
alarming,  and  is  usually  arrested  by  pledgets  of  cotton-wool  satu- 
rated with  a  five  or  ten  per  cent,  solution  of  antipyrin  or  cocaine, 
packed  into  the  nostril.  The  same  may  be  said  of  that  resulting 
from  violence,  excepting  only  fracture  of  the  base  of  the  skull^ 
associated  with  rupture  of  a  venous  sinus,  or  of  the  internal 
carotid  artery.  Of  nose-bleeding  due  to  local  causes  there  will 
often  be  found  some  constitutional  predisposing  factor,  and  nearly 
always  some  erosion  or  ulceration  in  the  nose.  Haemorrhage 
from  fibromata  and  malignant  growths  is  almost  invariably 
associated  with  ulceration.  Bleeding  from  the  nasal  cavities, 
uncomplicated  by  evident  rhinal  disease,  is,  in  my  experience, 
nearly  always  from  the  artery  of  the  septum,  and  at  a  spot  at  the 
anterior  part  of  the  septum  where  this  artery  joins  with  the 
ascending  branch  of  the  descending  palatine  artery  near  the 
anterior  palatine  canal.  Spurs  are  very  frequent  at  this  spot, 
which,  from  their  growth,  tend  to  attenuate  the  mucous  mem- 
brane ;  moreover,  foreign  bodies  are  apt  to  accumulate  and  help  on 
the  formation  of  an  adherent  incrustation  at  this  spot,  and  these 
crusts,  when  suddenly  removed  by  picking,  violent  blowing  of  the 
nose,  or  by  sneezing,  leave  a  breach  of  continuity  of  the  epithelial 
covering  of  the  spur.  Haemorrhage  is  not  uncommon  in  the 
ulcerative  processes  of  syphilis,  lupus,  lepra,  and  other  dyscrasiae. 
In  lepra  it  is  said  by  Hillis  to  be  invariable,  and  to  constitute 
the  earliest  premonitory  symptom  of  the  disease. 

As  regards  constitutional  factors  tending  to  epistaxis,  with 
or  without  erosions  of  the  mucous  membrane,  the  influence  of 
the  generative  function  can  be  first  considered,  because  it  repre- 
sents the  slightest  departure  from  the  normal.  I  have  already 
pointed  out  the  connection,  between  sexual  irritation  and  tur- 
gescence  of  the  turbinated  corpora  cavernosa,  and  it  is  not 
surprising  that  nose-bleeding  is  frequent  about  puberty,  is  often 
the  sequel  of  masturbation,   and    is   occasionally  a   form  of 


EPISTAXIS,  OR  RHINORRHAGIA. 


vicarious  menstruation.  Of  blood  conditions  predisposing  to 
epistaxis,  I  need  do  no  more  here  than  enumerate  the  chief, 
viz.  :  haemophiha,  purpura,  scurvy,  anaemia,  leukaemia,  plethora  ; 
eruptive  and  relapsing  fevers ;  acute  yellow  atrophy  and  phos- 
phorus poisoning,  A  diseased  and  weak  state  of  the  vessels 
may  exist  in  old  age,  in  atheromatous  conditions  generally,  in' 
syphilis,  phthisis  and  alcoholism.  Increased  blood-pressure  may 
be  a  factor  of  epistaxis  in  diseases  of  the  heart,  liver,  lungs  and 
kidney,  associated  with  obstructions  to  the  circulation,  and  in 
such  circumstances  is  often  a  warning  of  impending  apoplexy. 
In  my  own  practice  I  have  more  than  once  been  puzzled  until' 
the  urine  has  been  tested,  and  revealed  the  presence  of  albumen  ; 
and  I  have  seen  three  or  four  cases  in  which  it  was  associated 
with  the  condition  of  chronic  bronchitis,  emphysema,  and  dilated 
right  heart. 

Treatment. — As  already  mentioned,  after  nasal  operations 
the  bleeding  can  usually  be  checked  by  packing  the  nostrils  with 
pledgets  of  cotton-wool  soaked  in  a  solution  of  cocaine  ;  should  this 
fail,  antipyrin  in  five  per  cent,  solution  or  hazeline  may  succeed. 
Simply  packing  the  nose  with  cotton-wool  with  digital  com- 
pression is  often  efficacious.  When  the  epistaxis  is  not  traumatic 
in  origin  the  bleeding  spot  should  be  sought  for,  and  pressure 
applied,  if  possible,  over  it  by  the  above  means.  Applications  of 
ice-cold  water  to  the  interior  and  exterior  of  the  nose  constitute  a 
very  favourite  remedy  ;  they  act  by  causing  constriction  of  the  small 
vessels.  In  my  own  experience,  however,  especially  in  connection 
with  haemorrhage  in  the  naso-pharynx,  hot  water  is  often  more 
valuable  as  a  douche.  It  first  clears  away  all  imperfectly  formed 
clots,  and  then  favours  the  firm  coagulation  of  the  oozing  blood. 

Astringent  douches  often  produce  anosmia  and  other  damage. 
Styptic  colloid  on  cotton-wool  pledgets  is  useful  when  the- 
haemorrhage  is  from  the  anterior  part  of  the  septum.  When 
there  is  ulceration  at  this  situation  slight  galvano-cauterization 
will  often  promote  cicatrization.  Sedative  and  stimulating  oint- 
ments assist  the  healing  process  and  prevent  further  incrusta- 
tions. If  these  measures  fail,  the  posterior  nares  must  be  plugged 
by  means  of  Bellocq's  apparatus.  The  procedure  is  so  fully 
described  in  surgical  manuals  that  I  need  not  detail  it  here. 

Constitutional  treatment  appropriate  to  the  condition  of  the 
patient  must  be  also  adopted,  and  any  errors  of  living,  diet,, 
hygiene,  etc.,  corrected. 


624 


DISEASES  OF  THE  THROAT  AND  NOSE. 


V.  NEUROSES. 

ANOSMIA,  OR  ANOSPHRESIA. 

When  impaired  smell  depends  on  obliteration  of  the  '  olfactory 
slit/  as  in  the  case  of  a  hypertrophied  middle  turbinated  body 
touching  the  septum,  or  when  a  deviated  septum  is  so  deflected 
as  to  touch  the  middle  turbinal,  the  treatment  is  obvious  and 
nearly  always  satisfactory,  unless  the  abeyance  of  olfaction  is  very 
marked,  and  of  long  standing.  The  same  may  be  said  of  anosmia 
the  result  of  polypi,  in  which  cases  the  sense  of  smell  usually 
returns  after  eradication;  in  some  instances,  however,  the  pressure 
of  growths  on  the  delicate  olfactory  area  permanently  injures  the 
mucous  membrane  and  nerve-endings ;  this  is  especially  so  in 
fibromatous  and  in  sarcomatous  growths  which  invade  the  sensory 
areas,  and  permanently  interfere  with  olfaction.  Anterior  stenosis 
from  inferior  turbinated  hypertrophy,  without  obliteration  of  the 
middle  passage  and  olfactory  slit,  causes  only  impaired  smell ; 
moreover,  in  such  cases  the  taste  of  flavours  is  generally  not  inter- 
fered with,  unless  there  is  corresponding  post-nasal  stenosis.  On 
relieving  the  stenosis,  the  sense  of  smell  generally  returns.  The 
progress  towards  recovery  or  otherwise  of  this  symptom  under 
treatment  may  be  conveniently  measured  by  Zwardermaker's 
olfactometer. 

In  atrophitic,  syphilitic,  and  caseous  rhinitis,  as  well  as  in  some 
long-standing  forms  of  chronic  hypertrophic  rhinitis,  the  olfactory 
area  is  so  involved  by  the  morbid  lesions  that  olfaction  is  greatty 
and  often  permanently  impaired.  Schultze's  sensitive  cells  may  be 
over-stimulated  and  injured  by  tobacco  smoke  and  irritating 
chemical  fumes.  Snuffs  of  tobacco,  and  nasal  powders  medicated 
with  morphia,  alum,  or  tannin,  may  also  occasionally  act  prejudi- 
cially. 

Lesions  of  the  olfactory  bulbs  and  tracts  and  of  the  intra- 
cranial centres,  whether  from  traumatism,  tumours,  abscesses, 
haemorrhages,  or  other  morbid  conditions,  often  cause  partial  or 
permanent  bilateral  or  unilateral  anosmia. 

In  addition  to  the  removal  of  any  intra-nasal  cause,  it  is  well  to 
administer  strychnine,  arsenic,  phosphide  of  zinc,  valerian,  and 
other  nerve  tonics  internally.  Sajous  recommends  one-fortieth 
of  a  grain  of  the  strychnine  to  two  grains  of  powdered  sugar  to 
be  used  as  a  snuff,  or  to  be  insufflated  into  the  olfactory  areas 
night  and  morning.  As  regards  electricity,  both  the  constant  and 
interrupted  currents  should  be  tried,  the  negative  pole  being 


FOREIGN  BODIES. 


625 


placed  at  the  root  of  the  nose  and  the  positive  at  the  occiput. 
Bosworth  has  advised  moderate  practice  with  different  odorous 
substances,  a  change  being  made  every  few  days.  I  have  had  but 
Httle  opportunity  of  testing  this  method  by  education,  which,  how- 
ever, could  be  conveniently  used  in  connection  with  the  olfacto- 
meter. 

PAROSMIA. 

This  condition,  which  consists  in  perverted  sensation — in  illu- 
sions and  delusions  of  smell — is  not  due  to  lesion  of  the  nasal- 
mucosa,  but  occurs  as  an  accidental  symptom  in  cases  of  lead- 
poisoning,  epilepsy,  locomotor  ataxy,  intra-cranial  disease,  and 
with  other  pathological  and  functional  morbid  conditions  of  the 
nervous  system.  The  condition  of  parosmia,  or,  as  Warden  calls 
it,  paraphresia,  is  often  associated  with  disordered  taste,  which  has 
been  termed  by  the  same  author  parageusia. 

VI.    FOREIGN  BODIES. 
PHYSICAL. 

Rhinoliths. — Independently  of  the  ordinary  foreign  substances, 
such  as  hairpins,  plum-stones,  etc.,  which  may  be  introduced 
into  the  nostrils  by  children,  lunatics,  and  malingerers,  there  are 
occasionally  found  calcareous  concretions,  which  are  mostly  the 
result  of  the  deposit  of  phosphate  of  lime  from  the  nasal  secretions 
around  a  piece  of  necrosed  bone,  blood-clot,  or  foreign  nucleus.  As 
the  rhinolith  increases  in  size  it  gives  rise  to  subjective  symptoms  of 
obstruction,  anosmia,  nasal  voice,  and  headache,  with  objective 
evidence  in  the  shape  of  an  accompanying  profuse  muco-purulent 
discharge.  A  nasal  calculus  appears  black  or  yellowish  on  visual 
inspection,  and  gives  a  gritty  sound  on  probing ;  foetor,  if  present,  is 
only  slight,  unless  there  is  concomitant  necrosis.  Such  bodies  can 
be  generally  removed  by  a  curette,  forceps,  or  snare.  They  are 
rarely  so  large  as  to  require  to  be  first  crushed.  If  not  readily 
seized  from  the  front,  Sajous'  plan  for  removing  any  foreign  body 
from  the  nose  should  be  adopted.  It  consists  of  passing  a  wire, 
or  long,  threaded  bodkin  or  Bellocq  snare,  through  the  nose  to 
the  pharynx,  attaching  a  lint  tampon,  and  by  vis  a  tergo  drawing 
the  foreign  body  to  the  anterior  nares. 

BIOLOGICAL. 

Larvse,  Fungi,  and  other  animal  and  vegetable  parasites  are 
rarely  met  with  in  the  nasal  cavities  in  this  country.  A  whiff  of 
chloroform  or  a  spray  of  alcohol  is  the  best  means  for  their  destruc- 
tion, followed  by  other  antiseptic  sprays,  douches,  or  ointments. 

40 


626 


DISEASES  OF  THE  THROAT  AND  NOSE. 


B.    ACCESSORY  CAVITIES. 

Diseases  of  the  accessory  cavities  received  but  scant  notice  in  the 
earher  days  of  throat  and  nose  speciahsm,  and  during  the  seven 
years  (1866-73)  with  which  I  was  associated  with  Morell  Mackenzie 
at  Golden  Square  I  never  saw  a  case.  Spencer  Watson  (1875) 
was  the  first  Enghsh  author  to  give  it  any  importance,  to 
describe  it  as  it  was  diagnosed  with  the  aid  of  the  nasal  speculum 
and  to  upset  the  traditionally  inaccurate  description  of  its  symp- 
toms. Early  in  1879  I  related  three  cases  at  the  Harveian  Society, 
but  it  is  only  within  the  last  five  or  seven  years  that  diseases  of 
the  maxillary  antrum  from  other  causes  than  a  decayed  tooth 
have  been  recognised  and  differentiated  by  the  scientific  rhino- 
logist,  and  even  more  recently  that  equal  attention  has  been 
given  to  diseases  of  the  frontal,  ethmoidal  and  sphenoidal  cavities. 
To  appreciate  the  signs,  symptoms,  differential  diagnosis,  and 
treatment  of  disease  in  these  regions  requires  a  very  careful  and 
special  study  of  their  anatomy ;  but  for  this  purpose  the  reader 
must  be  referred  to  the  advanced  text-books. 

DISEASES  OF  THE  MAXILLARY  ANTRUM. 

Simple  catarrh  of  the  antrum  of  Highmore  may  doubtless 
occasionally  exist,  but  it  rarely  causes  symptoms,  and  I  am  myself 
not  aware  of  any  case  in  which  a  simple  acute  mucous  catarrh 
has  led  to  suppuration. 

Empyema  of  the  Maxillary  Antrum. — This  condition  is  usually 
unilateral.  The  commonest  cause  is  probably  a  carious  condition 
of  the  teeth  in  the  upper  jaw,  usually  either  the  bicuspids  or  front 
molars.  Certainly  carious  teeth  have  been  present  and  causal  in 
by  far  the  majority  of  the  cases  that  I  have  had  under  my  care, 
numbering  over  sixty  in  the  last  eighteen  years,  independent  of 
those  of  which  I  had  knowledge  in  the  practice  of  my  hospital 
colleagues.  It  may  be  true  that  exceptionally  the  condition  of  the 
teeth  is  the  result  of  a  primary  suppurative  catarrh  of  the  antral 
cavity,  though  such  a  sequence  has  not,  so  far  as  I  could  judge, 
occurred  in  my  experience,  and  is  in  any  case  difficult  to  decide. 

Moreau  Brown  (Chicago)  is  somewhat  exceptional  among 
observers  in  ascribing  to  taking  cold  a  more  prominent  posi- 
tion than  is  generally  allowed,  and  reports  that  out  of  twenty-one 
cases  of  the  disease,  nine  arose  from  this  simple  cause.  He  also 
gives  two  out  of  this  number  as  having  followed  directly  on  at- 
tacks of  epidemic  influenza.  This  is  a  very  large  proportion,  and 
it  is  difficult  to  believe  that  a  suppurative  process  could  follow  a 


DISEASES  OF  THE  ACCESSORY  CAVITIES. 


627 


simple  catarrh  in  the  absence  of  their  disease  in  a  tooth,  or  some 
organic  stenosis  of  the  normal  ostium  maxillare.  Probably  in 
these  cases  a  latent  empyema  has  previously  existed. 

Amongst  other  primary  causes  are  extension  of  an  atrophic 
or  other  catarrhal  condition  from  the  nasal  fossae  to  the  sinus, 
especially  in  syphilitic  and  strumous  subjects.  This  also  is 
probably  but  a  rare  cause  of  antral  suppuration,  though  perhaps 
not  so  rare  as  has  been  formerly  believed.  Next  in  frequency  to 
diseased  teeth  as  factors  are,  undoubtedly,  intra-antral  polypi, 
which  make  their  way  through  the  ostium  maxillare  into  the  nose, 
and  whose  source  of  origin  is  only  correctly  diagnosed  as  the 
nostrils  are  cleared.  In  such  a  case  there  is  often  considerable 
swelling  of  the  mucous  membrane  around  the  nasal  opening 
from  the  antrum,  giving  rise  to  an  erroneous  diagnosis  of  hyper- 
trophic rhinitis  as  the  primary  cause  of  the  empyema.  This 
blocking  of  the  hiatus  leads  to  retention  of  the  secretion,  which 
sooner  or  later  becomes  purulent ;  a  permanent  change  in  the 
mucous  lining  and  in  the  character  of  the  secretion  supervenes, 
and  if  this  is  of  long  duration  a  foetid  odour  results.  Two  of 
the  comparatively  few  cases  which  I  have  seen  of  true  empyema 
of  the  antrum  not  depending  on  dental  disease  were  due  to  antral 
polypus  ;  one  curiously  enough  was  bi-lateral.  The  third  occurred 
as  the  result  of  a  cauterization  of  the  base  of  a  nasal  polypus 
arising  near  to  the  hiatus. 

Amongst  other  causes  of  antral  disease,  Moreau  Brown  makes 
brief  mention  of  '  stenosis  or  closure  of  the  ostium  maxillare  by 
intra-nasal  tumours,  traumatism,  extension  of  catarrhal  inflamma- 
tion from  the  nasal  and  accessory  cavities,  suppuration,  degenera- 
tion of  cysts,  dentigerous  cysts  owing  to  error  of  development 
and  eruption  of  the  teeth,  epidemic  furunculosis,  scorbutus,  mer- 
curialism,  infection — erysipelas  and  the  exanthemata — (one  case 
of  erysipelas  has  been  reported  by  Luc),  foreign  bodies  (teeth), 
papillary  and  polypoid  degeneration  of  the  mucosa,  polypi  ex- 
tending into,  or  taking  their  origin  from,  the  margin  of  the  ostium 
neoplasms,  and  la  grippe.' 

I  have  seen  several  cases  of  purulent  rhinitis  due  to  insanitary 
causes,  which  apparently  extended  to  the  antrum,  but  which,  yield- 
ing to  suitable  hygienic  and  constitutional  measures,  as  well  as 
to  antiseptic  and  astringent  local  treatment,  are  not  worthy  to 
be  considered  as  examples  of  true  empyema. 

Symptoms. — As  I  pointed  out  in  a  paper  I  read  at  the  Harveian 
Society  in  February,  1879,  the  ordinary  symptoms  usually  de- 
scribed in  text-books,  such  as  dull  aching  pains  in  the  cheek, 

40 — 2 


628 


DISEASES  OF  THE  THROAT  AND  NOSE. 


with  heat,  redness,  and  fulness  of  the  soft  parts  externally,  even 
to  expansion  of  the  whole  jaw,  are  chiefly  conspicuous  by  their 
absence,  except  in  those  rare  cases  in  which  the  normal  antral 
aperture  is  actually  occluded  or  absent,  or  in  the  presence  of  a 
neoplasm  or  cystic  tumour.  I  was  not  at  that  time  aware  that 
in  this  observation  I  had  been  anticipated  in  1875  by  Spencer 
Watson. 

Foetor  is  not  always  present,  but  when  evinced  can  usually  be 
distinguished  from  the  ozaina  of  atrophic  rhinitis  by  observance 
of  the  hints  already  detailed  at  pages  584,  585.  When  a  tooth  is 
at  fault,  as  can  generally  be  ascertained  on  inspection,  there 
will  be  found  either  the  site  of  a  removed  tooth,  the  remains  of 
a  stump,  or,  possibly,  a  "  filled  "  cavity,  which  has  prevented 
drainage  and  induced  an  abscess  at  the  root.  Diagnosis  on 
this  point  will  be  confirmed  by  history  of  severe  toothache  or  of 
intra-nasal  pain,  at  or  about  the  time  that  the  nasal  flow  com- 
menced. Occasionally  there  may  be  seen  swelling  or  redness,  or, 
in  other  cases,  a  shrinking  of  the  gum.  When  dental  disease  is 
not  obvious  on  mere  ocular  inspection  it  sometimes  becomes 
evident  on  digital  palpation  or  percussion  of  the  teeth  separately  ; 
the  resultant  sensation,  even  where  toothache  has  ceased,  is  one 
of  tenderness,  especially  in  the  region  of  the  canine  fossa.  This 
tenderness  is  also  felt  in  the  ordinary  pressure  of  mastication. 
McBride  calls  attention  to  '  a  marked  redness  of  the  gingival 
mucous  membrane  of  the  affected  side.'  Consultation  with  a 
dental  surgeon  is  recommended  where  there  is  any  doubt  as  to 
the  condition  of  the  teeth,  and  especially  with  a  view  to  selection 
of  the  site  for  operation  where  several  are  diseased,  or  where 
there  is  not  already  an  empty  socket.  In  cases  where  the  nasal 
orifice  is  closed,  in  addition  to  the  objective  evidence  of  disten- 
sion, intra-  and  supra-orbital  neuralgia  and  diplopia  may  be 
observed.  Otherwise,  as  elsewhere  observed,  these  signs  indicate 
ethmoidal  or  sphenoidal  complication,  for  it  must  once  more  be 
remarked  that  in  many  cases  no  symptoms  maybe  complained  of, 
except  that  of  discharge,  the  site  and  character  of  which  must 
determine  the  diagnosis. 

The  main  diagnostic  point  of  antral  suppuration  is  that  the  dis- 
charge is  unilateral,  of  very  fluid  consistence,  of  pale  lemon-yellow 
colour,  and,  as  a  rule,  unconnected  with  an}-  ulceration  or  inflam- 
mation of  the  rhinal  mucous  membrane  of  the  affected  side.  On 
the  contrary,  the  membrane  is  often  pallid  and  sodden,  even  to 
the  extent  of  oedema.  In  some  cases  it  is  atrophied.  But  above 
all,  the  patient  is  always  aware  of  the  oftensive  character  of  the 
flux,  which  is  rarely  the  case  in  the  oza^na  of  atrophic  rhinitis ; 


DISEASES  OE  THE  ACCESSORY  CAVITIES.  629 

this  is  because  in  the  latter  disease  the  olfactory  region  is  invaded, 
which  is  not  the  case  in  abscess  of  the  antrum.  For  the  same 
reason  neither  the  sense  of  smell  nor  of  taste  is  much  impaired. 
On  visual  examination  of  the  (illuminated)  nasal  cavities  pus  of 
the  colour  described  will  almost  always  be  seen  to  be  oozing  from 
under  the  anterior  extremity  of  the  middle  turbinal  body  of  one 
side.  If  this  be  gently  wiped  away  with  cotton-wool  on  a  probe, 
and  the  patient  made  to  sneeze,  or  to  lie  on  a  couch  with  the 
head  slightly  bent  downwards,  the  discharge  will  often  re-appear. 
Exceptionally  the  purulent  contents  of  the  antrum  will  become 
caseated,  and  both  objective  and  subjective  signs  will  be  absent 
for  many  years,  until  some  acute  exacerbation  brings  about  such 
renewed  activity  as  to  lead  to  its  identification.  Percussion  and 
succussion  of  the  antrum  itself  are  diagnostic  aids  of  but  doubtful 
value,  and  whilst  not  required  in  well-marked  cases,  are  not  often 
capable  of  yielding  any  positive  evidence  of  value  in  others.  My 
recent  personal  experience  of  illumination  of  the  antral  cavity 
by  means  of  an  electric  light  placed  in  the  mouth,  inclines  me 
to  modify  my  former  agreement  with  Mr.  Christopher  Heath 
that  to  the  practical  surgeon  the  procedure  is  in  some  cases 
unnecessary,  though  it  is  doubtless  misleading,  in  view  of  the  fact 
that  bones  vary  so  much  in  their  degree  of  thickness  that  no  cer- 
tainty would  be  felt  even  if  the  antrum  remained  dark  in  spite  of 
attempted  diagnostic  illumination  by  the  electric  lamp.  More- 
over, as  one  of  my  drawings  in  this  work  indicates,  as  well  as 
m.any  of  those  of  Zuckerkandl,  the  cavity  of  one  antrum  is  often 
very  small,  whilst  its  fellow  may  be  unusually  capacious. 

Nevertheless,  the  investigations  of  such  careful  observers  as 
Voltolini,  Heryng,  Luc  and  Ruault  on  the  Continent,  and  Robertson 
in  this  country,  cannot  be  lightly  dismissed.  The  general  result 
of  their  investigations  is  that,  in  cases  when  the  antrum  is  healthy, 
an  infra-ocular  crescent  of  translucency  is  observed  when  an 
electric  light  is  placed  within  the  mouth,  other  light  being 
excluded  by  covering  the  heads  of  both  patient  and  observer 
with  a  black  hood  or  curtain.  The  absence  of  this  crescent,  or  a 
marked  diminution  of  transparency  on  one  side,  constitutes  the 
differential  element  of  diagnosis.  Ruault  has  well  remarked, 
having  on  one  occasion  been  disappointed  not  to  find  pus  in  a 
case  where  transillumination  showed  a  beautiful  sub-orbital 
umbra,  '  We  can  have  opacity  without  emp3'ema,  but  we  cannot 
have  empyema  without  opacity.'  Probably  if  there  be  not 
empyema  in  such  a  case,  there  is  some  other  intra-antral  disease 
which  accounts  for  the  umbra. 

The  same  observer  has  also  found  by  putting  the  light  to  one 


630 


DISEASES  OF  THE  THROAT  AND  NOSE. 


or  other  side  of  the  buccal  cavity  and  using  a  nasal  speculum, 
that  there  is  a  diminished  luminosity  of  the  nasal  wall  of  the 
antrum  on  the  affected  side. 

Another  point  of  diagnosis,  on  which,  however,  there  is  not 
complete  agreement,  is  that  in  those  cases  where  it  is  possible 
to  illuminate  the  pupils,  the  pupil  corresponding  to  the  healthy 
antrum  is  brighter  and  redder  than  that  corresponding  to  the 
cavity  which  is  diseased.  With  regard  to  all  these  experiments, 
Ziem  has  pointed  out  that  illumination  is  only  of  value  in  pro- 
portion as  the  antrum  is  filled  with  pus,  and  is  almost  useless 
when  there  is  but  little. 

Other  methods  of  diagnosis  are  those  of  Mickulicz,  with  the 
modifications  of  Lichtwitz,  Tornwaldt,  etc.  The  nasal  wall  of 
the  antrum  is  punctured  in  the  inferior  meatus,  and  then  by 
syringing  through  the  opening,  observation  is  made  as  to  whether 
pus  comes  out  through  the  normal  ostium  maxillare.  In  one  case 
in  which  this  method  was  employed  at  our  hospital,  the  issue  of 
pus  demonstrated  the  existence  of  a  dental  sinus  which  had 
been  hitherto  overlooked. 

Luc  has  used  an  aspirating  syringe,  and  some  timorous  surgeons 
even  open  the  canine  fossa  and  employ  electric  search  lamps  for 
the  purpose  of  simple  diagnosis. 

And  yet  another  method  has  been  reported  by  Moreau  Brown 
in  which  the  test  is  that  of  peroxide  of  hydrogen.  The  nasal 
passage  is  cocainized  and,  with  a  hypodermic  syringe  with  long 
cannula  bent  to  a  right  angle  within  a  quarter  of  an  inch  of  the 
distal  end,  a  solution  of  peroxide  of  hydrogen  (i  to  12  of  water)  is 
projected  into  the  antrum  through  the  hiatus  semilunaris.  If 
pus  is  present,  it  is  driven  out  and  fills  the  nose  with  white  foam. 
With  the  use  of  this  test,  which  the  author  maintains  is  very 
certain,  can  be  differentiated  purulency  of  the  maxillary  sinus 
from  other  sources  of  pus  discharged  into  the  nose.  Notwith- 
standing that  in  ig  cases  this  observer  diagnosed  15  by  this 
method,  it  cannot  be  said  to  be  easy  of  accomplishment,  or  by 
any  means  free  from  inconvenience  to  the  patient. 

Surgeons  who  may  feel  hesitation  in  arriving  at  a  decisive 
opinion  need  not  fear  to  make  a  diagnostic  puncture  at  the  site  of 
the  canine  fossa,  through  the  alveolus  in  the  situation  of  a 
previously  removed  tooth,  or  through  the  wall  of  the  middle  or 
inferior,  meatus  of  the  nose.  The  natural  opening  can  sometimes 
be  easily  catheterized.  Personally  I  have  but  once  tapped  an 
antrum  without  finding  pus ;  but  Ziem  reports  this  occurrence  in 
nine  per  cent,  of  a  series  of  47  cases,  a  circumstance  which  seems 


DISEASES  OF  THE  ACCESSORY  CAVITIES.  631 

to  indicate  that  there  is  undue  reactionary  activity  in  antral 
surgery  against  the  general  apathy  of  ten  years  ago.  Failure  to 
find  pus  as  an  immediate  result  of  operation  must  not,  however,  be 
too  hastily  accepted  as  evidence  of  erroneous  diagnosis,  as  on 
more  than  one  occasion  a  purulent  discharge  has  been  delayed 
for  twelve  or  twenty-four  hours  after  drilling,  especially  where  the 
purulent  contents  have  become  caseated,  or  where,  as  is  not  in- 
frequent, the  antral  contents  consist  of  organized  tissue. 

Treatment  is  best  effected  by  perforation  of  the  antrum,  by 
means  of  a  trocar  or  drill,  through  the  socket  of  a  lost  tooth,  or 
by  removal  of  any  decayed  one,  or  portion  of  one,  thought  to  be 
the  cause  of  the  abscess.  Personally,  I  should  never  counten- 
ance the  making  an  opening  for  therapeutic  purposes  except  in 
this  the  most  dependent  situation,  and  consequently  that  which 
best  assures  a  complete  emptying  of  the  cavity  not  only  on  the 
first  occasion,  but  also  for  so  long  as  it  is  necessary  to  keep  the 
antrum  patent ;  for  it  has  to  be  borne  in  mind  that  the  opening  is 
to  be  maintained,  and  the  cavity  syringed  with  an  instrument 
fitted  so  that  the  fluid  employed  (antiseptic  or  detergent),  instead 
of  returning  through  this  alveolar  channel,  can  pass  through 
the  nasal  orifice  of  the  antrum. 

For  the  purpose  of  this  continuance  of  the  irrigating  process, 
my  colleague,  Mr.  George  Wallis,  who  has  rendered  dental  assist- 
ance in  all  my  cases,  hospital  and  private,  for  the  past  twenty 
years,  has  ingeniously  made  and  fitted  gold  and  vulcanite  plates, 
with  cannula  opening  and  plug.  The  result  has  been  almost 
universally  satisfactory,  though  the  length  of  time  occupied  in 
effecting  a  complete  cure  has  varied  from  a  few  weeks  or  months 
to  (in  one  case)  even  years.  The  use  of  the  little  gold  plug  pre- 
vents food  from  passing  into  the  antrum  during  mastication,  and 
obviates  one  of  the  minor  reasons  given  for  making  the  opening 
at  the  alveolar  apophysis. 

If  the  nasal  opening  be  not  already  patent  it  must  be  made  so 
by  the  reduction  of  surrounding  hypertrophy,  or  by  catheterization. 

To  decide  when  it  is  really  safe  to  allow  the  surgical  opening  to 
close  is,  as  Heath  has  said,  a  point  of  some  nicety  ;  for  if  it  be 
allowed  to  close  too  soon  it  is  often  necessary  to  make  a  fresh 
opening  ;  and  if  it  be  maintained  patent  too  long,  the  condition 
may  become  chronic.  This  last  is,  however,  more  likely  to  occur 
if  irrigation  be  too  long  continued.  I  am  in  the  habit  of  advising 
my  patients,  so  soon  as  the  fluid  syringed  into  the  cavity  comes 
clear,  to  keep  the  cannula  plugged  for  a  gradually  increased 
interval,  and  only  when  the  immunity  from  foetor  and  pus  is 


632 


DISEASES  OF  THE  THROAT  AND  NOSE, 


maintained  after  closure  for  a  period  of  ten  to  fifteen  days,  do  I 
permit  removal  of  the  plug.  Nevertheless,  I  have  seen  two  cases 
of  relapse,  one  at  an  interval  of  weeks,  another  after  many  years. 
In  one  of  my  earliest  cases  I  only  succeeded  in  effecting  a  cure 
after  searing  the  cavity  of  the  antrum  by  means  of  galvano- 
cautery,  introduced  through  the  alveolar  aperture.  Another  very 
chronic  case  was  cured  by  the  patient  inadvertently  using  a 
solution  of  chloride  of  zinc,  40  grains  to  the  ounce,  which  had 
been  prescribed  for  dilution  to  an  eighth  of  that  strength. 

If  the  disease  is  of  undoubtedly  nasal  origin,  the  cause,  such  as 
polypi  and  hypertrophy  in  the  neighbourhood  of  the  middle 
meatus,  naturally  requires  treatment.  Catheterization  of  the 
normal  opening  should  be  attempted  by  means  of  a  fine  catheter 
with  a  re-curved  point,  and  if  successful  an  antiseptic  lotion  can  be 
injected  through  it.  The  hypertrophy  of  the  mucous  membrane 
around  the  stenotic  orifice  is  best  reduced  by  local  applications  of 
the  galvano-cautery.  Politzerization  of  the  nasal  cavities  is  a 
useful  procedure  when  stenosis  is  not  complete. 

If  an  attempt  to  reduce  the  stenosis  of  the  natural  orifice,  and 
to  medicate  the  cavity  by  means  of  the  catheter,  fail,  as  it  often 
does,  several  courses  are  open :  the  antrum  can  be  tapped 
through  a  tooth  cavity,  through  either  the  middle  or  inferior 
meatus  of  the  nose,  or  through  the  canine  fossa.  I  myself  always 
prefer  to  drain  through  the  alveolar  process,  except  in  the  doubt- 
ful cases  in  which,  the  teeth  being  perfectly  sound,  one  would 
hesitate  to  sacrifice  a  healthy  tooth.  Here  the  practice  of  Heath 
to  puncture  the  antrum  above  the  alveolus  may  be  preferably 
adopted,  for  in  perforating  through  the  inferior  meatus  we  do 
not  tap  the  pus  cavity  at  its  lowest  and  most  advantageous  point, 
as  in  the  alveolar  region,  and  both  rapidity  and  permanence  of 
cure  by  this  procedure  must  necessarily  be  more  tedious.  Should 
all  these  methods  fail,  it  is  no  doubt  good  surgery  to  make  a  con- 
siderable opening  through  the  canine  fossa,  and  thence  to  explore 
the  cavity,  with  a  view  to  remove  any  exuberance  of  granulation 
tissue  polypi  or  caseous  masses  which  ma)^  explain  failure.  The 
cavity  under  such  circumstances  has  with  advantage  been  cauter- 
ized, or  curetted  and  packed  with  iodoform,  and  subsequently 
irrigated  with  antiseptics — the  best  of  which  is  probably  a  solu- 
tion (i  to  1,000  or  2,000)  of  biniodide  of  mercury. 

Diseases  of  the  Frontal  Sinuses. — Catarrhal  suppuration  of 
these  cavities  is  much  more  commonly  found  in  association  with 
rhinitis,  both  simple  and  specific,  than  is  the  case  with  the 
antrum,  and   the  circumstance   may  possibly  depend  on  the 


DISEASES  OF  THE  ACCESSORY  CAVITIES. 


633 


morphological  differences  in  the  orifices  into  the  nose  of  the  respec- 
tive sinuses.  Such  suppuration  may  also  be  due  to  occlusion  of 
the  infundibular  orifice  either  by  reason  of  the  presence  of  nasal 
polypi  or  hypertrophies,  or  from  tumours,  such  as  myxomata 
growing  from  the  lining  of  the  sinus  itself.  One-sided  pain  over 
the  site  of  the  sinus,  often  too  hastily  dismissed  as  '  neuralgic,'  is 
the  prominent  symptom.  It  is  not,  however,  always  unilateral, 
and  is  usually  found  to  be  increased  by  pressure  over  the  upper 
margin  of  the  orbit.  I  have  relieved  many  such  cases  by  careful 
upward  catheterization  of  the  infundibulum  under  the  anterior 
extremity  of  the  middle  turbinated  body,  at  a  point  in  front  of 
the  hiatus  semilunaris.  An  intelligent  patient  can  often  be  taught 
to  irrigate  the  cavity  himself  by  this  means  through  the  natural 
opening.  If  the  obstruction  is  of  nasal  origin,  catheterization  and 
reduction  by  cautery  of  the  swollen  condition  of  the  mucous 
membrane  around  the  orifice,  constitutes  the  only  treatment 
necessary.  After  the  stenosis  has  been  relieved  the  secretions 
usually  assume  a  healthy  character  in  the  course  of  a  few  weeks. 
When  such  a  result  is  not  attained,  the  presence  of  a  growth  in 
the  sinus  is  to  be  suspected,  which  can  only  be  removed  by 
trephining  the  frontal  bone,  a  proceeding  for  details  of  which 
works  on  general  surgery  may  be  consulted. 

Morbid  conditions  of  the  Ethmoidal  cells,  independently  of 
those  of  acute  catarrh  and  suppuration,  have  been  already  dis- 
cussed at  some  length,  under  the  head  of  Ethmoiditis,  which  is, 
it  may  be  repeated,  in  any  case  a  very  uncommon  lesion,  and, 
when  not  the  result  of  syphilis,  is  probably  a  symptom  of 
malignant  disease. 

Bryan  of  Washington,  U.S.A.  {Trans.  Amer.  LaryngoL  Assoc., 
1892),  has  given  a  very  interesting  account  of  a  case  of  suppurat- 
ing ethmoiditis,  and  thrown  much  new  light  on  a  hitherto  not 
well-described  malady.  The  cause  in  this  case  was  traumatism, 
associated  with  an  attack  of  la  grippe.  He  concurs  in  my  views 
as  expressed  in  the  remarks  on  this  condition  on  page  588  under 
the  heading  oi  Rhinitis  Caseosa. 

With  regard  to  the  diagnosis  of  caries  in  this  situation,  it  has 
been  said  that  when  the  anterior  and  middle  ethmoidal  cells  are 
affected,  there  is  pain  in  the  forehead  and  top  of  the  head,  and  a 
feeling  of  pressure  behind  the  eyes,  this  may  be  uni-  or  bi-lateral  ; 
but  that  when  the  posterior  ethmoidal  cells  are  affected,  pain  is 
usually  situated  at  the  top  and  back  of  the  head. 

Max  Schaeffer  {Deutsche  Med.  Wochenschr.,  Oct.  9,  1890)  con- 
siders that  in  pain  we  have  a  reliable  symptom  in  differentiating 


634 


DISEASES  OF  THE  THROAT  AND  NOSE. 


abscesses  of  the  various  sinuses.  In  case  of  the  frontal  sinus 
pain  is  felt  at  the  root  of  the  nose,  and  extends  along  the  supra- 
orbital ridge,  while  in  ethmoidal  affections  it  extends  along  the 
infra-orbital  ridge,  and  in  maxillary  empyema  pain  is  often  con- 
spicuously absent.  My  own  experience  confirms  the  accuracy  of 
these  observations. 

Lesions  of  the  Sphenoidal  sinuses  may  be  either  of  a  syphilitic, 
tubercular,  or  polypoid  nature  ;  from  the  position  of  the  cavity 
an  exact  diagnosis  is  often  impossible,  but  the  symptoms  are  in 
the  main  similar  to  lesions  in  the  posterior  ethmoidal  cells,  with 
which  they  are  continuous.  Sphenoidal  discharges  may  be  the 
forerunner,  and  possibly  the  excitant,  of  obstinate  post-nasal 
catarrh.  Caseous  conditions  of  this  region  have  been  alluded  to 
under  rhinitis  caseosa. 

Prognosis  of  disease  in  these  situations  is  grave,  both  on 
account  of  their  proximity  to  the  brain,  and  of  the  anatomical 
difficulty  in  reaching  them  surgically. 

Treatment  will  generally  consist  in  irrigation  by  means  of 
spray  and  douches,  on  the  principles  so  frequently  explained 
under  previous  headings.  Catheterization,  which  I  have  proved 
to  be  quite  possible  on  the  cadaver,  is  not  an  operation  which  can 
be  carried  out  with  precision  on  the  living  subject,  and  is,  more- 
over, not  unattended  with  risk,  on  account  of  the  proximity  of 
the  cribriform  plate,  though  this  structure  may  be  avoided  by 
keeping  to  the  outer  side  of  the  middle  turbinal  body,  in  which 
direction  the  infundibulum  is  usually  found. 

The  same  caution  may  be  enjoined  with  regard  to  the  attempts 
at  curetting,  of  which  successful  cases  have  been  recorded. 

New  Growths  of  the  accessory  cavities  may  partake  of  any  of 
the  characters  of  those  which  affect  the  nasal  fossae  proper,  and 
have  been  frequently  alluded  to.  Their  further  discussion  would 
involve  a  too  lengthy  trespass  on  the  domains  of  general  surgery. 

C.    NASO-PHARYNGEAL  CAVITY. 

NASO-PHARYNGEAL,  OR  POST-NASAL,  CATARRH. 

This  condition,  characterized  by  accumulations  of  mucous  and 
muco-purulent  secretions  in  the  post-nasal  space,  is  now  generally 
recognised  by  modern  rhinologists  as  but  a  symptom  of  rhinitis 
proper,  but  it  may  exist  as  a  disease  per  se.  The  last  circum- 
stance is,  so  far  as  my  experience  serves,  rare  in  this  country,  but 
is  reported  to  be  very  prevalent  on  the  American  Continent,  where 
nearly  every  other  person  is  said  to  suffer  from  '  post-nasal  catarrh.' 


NASO-PHARYNGEAL,  OR  POST-NASAL,  CATARRH. 


635 


The  malady  may  be  either  acute,  subacute,  or  chronic,  the  latter 
being  the  form  usually  met  with  ;  the  morbid  lesion  is  commonly 
hypertrophic,  but  is  occasionally  characterized  in  the  later  stages 
of  chronicity  by  atrophy  of  the  mucous  membrane. 

In  the  large  majority  of  cases  the  characteristic  tenacious 
post-nasal  accumulations  represent  the  thickened  and  altered 
secretions  which  have  been  poured  out  from  the  morbid  mucous 
lining  of  the  nasal  passages  proper,  or  of  the  accessory  cavities, 
notably  the  ethmoidal  and  sphenoidal  sinuses.  Of  the  nasal  con- 
ditions of  which  such  catarrh  may  be  a  symptom,  the  most 
important  are  hypertrophic  rhinitis,  together  with  spurs  and 
deviations  of  the  septum,  polypi  and  other  intra-nasal  or  naso- 
pharyngeal growths.  Atrophic  rhinitis  is  frequently  associated 
with  naso-pharyngitis  sicca. 

Etiology. — When  chronic  naso-pharyngitis  exists  as  an  idio- 
pathic disease,  which  is  said  to  be  the  case  in  '  American  catarrh,' 
amongst  the  commoner  exciting  causes  may  be  cited  a  dry  and 
dusty  condition  of  the  atmosphere,  tobacco  and  other  fumes,  and 
the  use  of  ardent  spirits.  Scrofula,  gout,  and  rheumatism  are 
predisposing  factors,  as  are  also  attacks  of  the  exanthemata. 
The  acute  variety  may  arise  afresh,  or  as  a  relapse,  in  an  indi- 
vidual suffering  from  chronic  post-nasal  catarrh,  through  exposure 
to  cold  and  wet. 

Pathology. — The  lesion  in  true  naso-pharyngitis  consists  in 
hypertrophy  of  the  mucous  lining  with  an  altered  condition  of  the 
glandular  structures.  The  tubular  glands  become  atrophied  and 
the  scattered  lymphoid  glandular  masses  as  well  as  the  remnant  of 
the  pharyngeal  tonsil  are  more  or  less  accentuated.  This 
hypertrophy  in  adults  is  not  of  the  exuberant  vegetation-like 
nature  observed  in  children,  and  known  as  '  adenoid  growths' ; 
but  appears  as  more  or  less  thickened  and  hardened  cushion-like 
masses,  with  crypts  or  fissures,  which  constitute  the  secreting 
areas.  The  secretion  is  modified,  being  much  more  tenacious, 
thickened,  and  deficient  in  fluid,  than  the  normal.  On  this  account 
the  larger  fissures  or  crypts  become  sometimes  blocked  by  retained 
secretion,  and  occasionally  this  process  leads  to  the  formation  of 
actual  cysts. 

When  the  true  *  bursa  pharyngea  '  of  Luschka  exists,  this  may 
be  the  seat  of  a  thick  muco-purulent  discharge,  and  even  become 
cystic,  the  bursa  being  affected,  in  fact,  in  exactly  the  same  way 
as  are  the  other  crypts  or  fissures.  Tornwaldt  believes  that 
catarrh  of  Luschka's  pouch.  Bursitis,  is  par  excellence  the  lesion  of 
post-nasal  catarrh,  a  view  which  has  not,  however,  been  endorsed 


636 


DISEASES  OF  THE  THROAT  AND  NOSE. 


in  this  country.  I  have  previously  pointed  out  that  it  is  but  an 
exceptional  lesion,  and  have  only  to  add  that  the  bursa  itself  is 
rarely  demonstrable  by  post-mortem  examination  in  a  naso-pharynx, 
whether  in  health  or  disease. 

Symptoms. — These  depend  on  the  presence  of  a  thick  tenacious 
mucous  or  muco-purulent  secretion  in  the  post-nasal  space,  which 
is  felt  by  the  patient,  and,  acting  as  an  irritant,  induces  him  to 
make  '  hawking '  attempts  to  dislodge  the  accumulation ;  such 
attempts  often  bring  about  cough  and  vomiting,  and  are  not 
unfrequently  accompanied  by  what  I  have  termed  pharyngeal 
tenesmus.  This  latter  is  more  marked  when  there  is  a  super- 
added lingual  varix,  a  condition  which  is  largely  dependent  on 
nasal  stenosis.  In  addition  to  the  sensation  of  a  foreign  matter 
in  the  throat,  there  is  often  a  bad  taste  or  smell  in  the  mouth. 
Aprosexia  and  headache  are  frequently  complained  of,  and  reflex 
symptoms,  such  as  asthma,  are  exceptionally  present.  Deafness 
from  concomitant  Eustachian  catarrh  is  frequently  co-existent. 
It  has  been  recently  stated  that  no  naso-pharyngeal  disease,  except 
adenoid  vegetations,  is  responsible  for  impairment  of  hearing  by 
continuity.  This,  if  correct,  is  but  half  a  truth,  for  it  should 
always  be  remembered  that  many  cases  of  naso-pharyngeal  catarrh 
in  the  adult,  as  well  as  many  of  chronic  non-suppurative  middle 
ear  deafness,  are  really  the  result  of  neglected  adenoid  vegetations 
in  early  life. 

Objective  Appearances. — On  posterior  rhinoscopic  examina- 
tion the  naso-pharyngeal  mucosa  is  more  or  less  obscured  by  the 
muco-purulent  accumulations  which  are  especially  abundant  in 
the  neighbourhood  of  the  posterior  nares.  Eustachian  tubes, 
Rosenmiiller's  fossa,  or  over  an  enlarged  cryptic  cavity  or  bursa. 
On  cleansing  the  post-nasal  space  of  such  accumulations  by  the 
coarse  spray  or  brush,  existence  of  the  cushion-like  masses — 
remnants  of  the  pharyngeal  tonsil — will  be  evident  on  posterior 
rhinoscopy.  A  catarrhal  bursal  cavity  may  be  detected  by  the 
presence  of  a  firm  plug  of  mucous  or  coagulated  lymph  blocking 
its  orifices,  and  digital  examination  may  possibly  reveal  the 
presence  of  any  fluctuating  cystic  cavity.  For  further  details  as 
to  the  pharyngeal  symptoms  and  evidences  of  catarrh,  the  reader 
is  referred  back  to  the  description  of  those  characteristic  of  chronic 
pharyngitis  (pp.  195  ct  scq.). 

Treatment. — Palliative  therapeutics,  in  the  shape  of  post-nasal 
pigments,  douches,  and  sprays,  are  but  subsidiary  to  previous 
more  radical  measures,  which  consist  in  a  thorough  scarifying 
or  curetting  of  the  morbid  areas,  catarrhal   crypts  or  fissures. 


NASO-PHAKYNGEAL,  OR  POST-NASAL,  CATARRH. 


637 


Like  conditions  of  the  bursa  should  always  be  looked  for,  and 
when  found  to  be  diseased  should  be  thoroughly  curetted  and 
afterwards  cauterized  by  the  galvanic  or  other  form  of  cautery. 
Cysts  to  be  detected  only  by  palpation  can  usually  be  successfully 
treated  in  the  same  way.  Other  remedial  measures,  recom- 
mended as  applicable  to  chronic  pharyngitis,  will  be  found 
serviceable  when  the  catarrh  extends  to  the  naso-pharynx.  The 
condition  of  deafness  may  be  greatly  alleviated  by  cure  of  the 
naso-pharyngeal  catarrh,  but  may  in  many  cases  require  further 
special  measures  directed  to  the  auditory  apparatus. 

It  is  above  all  important  to  remember  that  all  or  any  of  the 
conditions,  embraced  under  the  term  post-nasal  catarrh,  may  be 
dependent  on  and  subordinate  to  nasal  stenosis,  and  this  fact  must 
dominate  all  treatment. 

HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL. 

Synonyms. — Adenoids,  or  adenoid  growths,  of  the  naso-pharynx, 
and  post-nasal  vegetations  or  growths. 

According  to.  literary  researches,  hypertrophies  of  the  naso- 
pharyngeal space  have  been  known  to  exist  since  the  time  of 
William  Hunter.  Czermak,  in  i860,  described  a  case  of  growths 
in  this  region  ;  and  in  1862  Sir  Andrew  Clark  wrote  a  short 
article  on  '  Naso-palatine  Gland  Disease.'  In  1865  Voltolini  and 
Loewenberg  separately  described  cases  of  deafness  associated 
with  vegetations  in  the  naso-pharynx.  The  frequency  and 
clinical  importance  of  these  hypertrophies  of  Luschka's  tonsil 
were,  however,  for  the  first  time  clearly  insisted  on  by  Meyer,  of 
Copenhagen,  in  1868.  This  accomplished  specialist,  with  a  record 
of  T02  cases,  gave  an  admirable  account  of  the  symptoms  and 
treatment  of  the  condition  called  by  him,  as  a  result  of  micro- 
scopical examination,  adenoid  vegetations.  Since  1870  much 
active  investigation  has  been  expended  on  these  interesting  hyper- 
trophies, but  little  of  any  importance  has  been  contributed  which 
was  not  clearly  described  and  understood  by  Meyer,  and  almost 
all  that  is  new  has  been  the  invention  of  new  instruments  for 
their  ready  and  thorough  removal,  most  of  which,  numerous  as 
they  are,  have  been  of  service  chiefly  to  the  inventor.  But  in 
this  assertion  I  would  make  an  exception  in  favour  of  Guye,  of 
Amsterdam,  who  has  demonstrated  the  fact,  which  I  can  endorse 
from  long  personal  and  independent  experience,  that  the  educated 
index-finger  is  one  of  the  safest  and  most  efficient  eradicators, 
especially  for  infants  and  very  young  children. 

Etiology  and  Pathology. — It  has  long  been  known  that 


638 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Luschka's  tonsil,  which  is  of  large  size  in  children,  tends  to 
become  reduced  to  a  minimum  after  the  period  of  growth  is 
over,  and  that  in  most  individuals  of  over  thirty  years  of  age  it  is 
only  demonstrable  on  minute  examination.  All  leucocyte-manu- 
facturing organs,  such  as  the  tonsils  and  lymphatic  glands, 
which  are  most  developed  and  active  during  the  period  of 
growth,  are  more  liable  to  hypertrophy  on  even  slight  irritation 
during  early  years  of  life.  Loewenberg  speaks  of  the  '  lymphatic 
temperament '  of  those  young  persons  whose  lymphatic  glands 
and  various  tonsils  easily  inflame  or  enlarge  on  slight  irritation- 
Such  a  condition  of  vulnerability  would  appear  to  be  nearly  allied 
to  struma,  but  this  diathetic  state  is  not  considered  to  constitute 
an  etiological  factor  by  Meyer,  Morell  Mackenzie,  Bosworth,  and 
other  observers.  Sajous,  writing  on  the  causation  of  adenoid 
growths,  correctly  places  most  importance  on  the  fact  that  '  the 
liability  to  hypertrophic  changes  to  which  the  (faucial)  tonsils 
are  susceptible  in  some  persons  exists  also  in  the  pharyngeal 
tonsil,'  and  adds  *  that  a  continued  or  often-repeated  inflamma- 
tory process  may  also  act  as  an  exciting  cause.  The  inherent 
deficiency  of  recuperative  powers  peculiar  to  lymphatic  glandular 
tissue  being  an  important  element  in  the  pathology  of  this,  as  it  is 
in  simple  chronic  inflammation,  the  hypertrophic  process  is  but 
the  result  of  the  continued  hyperplasia.' 

Doubtless  adenoid  growths  are  somewhat  more  common  in 
countries  of  humid  climate,  but  this  circumstance  has  been  con- 
siderably exaggerated  as  a  predisposing  factor,  especially  by  those 
who  have  claimed  diminished  prevalence  in  America  as  accounted 
for  by  improved  meteorological  surroundings  ;  for  Roe  and  others 
who  have  paid  attention  to  the  subject  have  given  contradictory 
evidence  which  is  unimpeachable. 

Most  specialists  regard  attacks  of  diphtheria,  of  the  exanthemata, 
and  other  fevers,  exhibiting  nasal  and  pharyngeal  inflammations 
as  frequent  factors  in  the  induction  of  hypertrophic  processes  in 
the  lymphoid  tissues  of  the  naso-pharynx.  I  would  be  inclined 
to  invert  this  statement  of  cause  and  effect  as  of  more  ordinary 
occurrence,  for  it  is  quite  as  frequent  in  my  experience  to  find 
tonsillar  hypertrophy  influencing  the  severity  of  an  acute  specific 
fever,  as  for  the  latter  to  be  directly  responsible  for  the  hyper- 
trophy. Some  analogy  may  be  found  in  the  circumstance  that 
typhoid  fever  becomes  rarer,  as  with  the  advance  of  age,  Peyer's 
glands  (the  discrete  intestinal  tonsil)  show  signs  of  disappearance. 
Hill  considers  insanitary  surroundings,  especially  in  individuals 
with  a  liabiHty  to  catarrh,  or  the  subjects  of  the  strumous, 
syphilitic,  and  rheumatic  diatheses,  as  potent  and  frequent  pre- 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL. 


639 


disposing  factors ;  whilst  attacks  of  the  exanthemata  and  filth 
diseases  associated  with  insanitary  surroundings  are  regarded  by 
him  as  the  more  usual  exciting  causes.  My  own  experience 
certainly  endorses  an  etiological  explanation  which  brings  out 
the  association  between  adenoid  growths  and  insanitary  sur- 
roundings; but  here,  again,  I  would  express  the  opinion  that 
the  lymphatic  temperament  predisposes  to  the  septic  inflamma- 
tion, which  may  in  turn  be  followed  by  further  hypertrophy. 
Hill's  statement  that  the  adenoid  overgrowth  is  due  to  the 
prevention  of  the  normal  tonsillar  function  of  leucocyte  migra- 
tion, by  diapedesis  into  the  pharynx,  by  reason  of  the  thickening 
and  impermeability  of  the  mucous  covering  of  the  tonsil,  induced 
by  contact  with  irritating  contaminations  of  the  nasal  secretions. 


Fig.  CCXXII. — Section  of  a  Stalactite  Adenoid  Growth  (under  a  low  power), 
showing  adenoid  ground  tissue  (b)  and  oval  and  rounded  lymphoid  follicles  (c)  ; 
one  space  (d)  in  which  the  follicle  has  been  voided  in  section  is  also  delineated  ;  the 
columnar  ciliated  epithelium  (a)  is  also  detached  at  places. 

will  doubtless  give  rise  to  further  investigation  on  this  point. 
Certainly  purulent  and  muco-purulent  nasal  catarrh  in  children, 
the  irritant  nature  of  which  is  shown  by  eczema  of  the  nostrils,  is 
almost  invariably  in  association  with  adenoid  overgrowth  of  the 
pharyngeal  tonsil ;  but  I  am  not  sure  that  the  purulent  catarrh  is 
always  primary,  for  I  have  seen  numerous  cases  in  which  removal 
of  the  growths  has  led  to  a  speedy  cure  of  the  discharge. 

Under  the  microscope  these  overgrowths  of  the  third  tonsil  are 
seen  to  be  of  such  a  structure  as  to  justify  the  terminology 
adopted  by  me  at  the  head  of  this  section.  The  'vegetations'  are 
not  new  growths,  but  merely  exuberant  outgrowths,  or  hyper- 
trophies, from  the  mucous  aspect  of  the  glands.  They  are  com- 
posed of  lymphoid  follicles,  embedded  circumferentially  in  the 
retiform  adenoid  tissue  of  His,  and  are  bounded,  apically  and 
laterally,  by  columnar  ciliated  epithelium ;  cilia,  however,  are 


640  DISEASES  OF  THE  THROAT  AND  NOSE. 


often  absent  at  points  of  frequent  contact  or  of  friction  with  the 
soft  palate. 

Symptoms,  Effects  and  Prognosis. — The  first  have  been 
frequently  alluded  to  in  previous  sections.  They  may  be  summed 
up  as  impairment  of  the  normal  nasal  respiration,  with  mouth- 
breathing  and  its  usual  complications  and  morbid  results.  The 
most  important  and  frequent  symptoms  calling  for  post-nasal 
treatment  are  those  connected  with  the  functions  of  respiration, 
audition,  voice-production,  and  articulation  (stammering  and 
stuttering) ;  but  such  errors  of  function  are  often  complicated  by 
headache,  aprosexia,  backwardness  and  stupidity,  derangements 
of  spirits  and  energy,  nightmare,  with  snoring  and  disturbed 
sleep,  and  a  dry  mouth  and  throat  on  waking ;  laryngeal  and 
pulmonary  troubles,  disordered  digestion,  and  reflex  croup  and 
cough  are  not  infrequent ;  indeed,  I  believe  that  in  almost  all, 
if  not  all,  cases  of  laryngismus  stridulus,  or  false  croup,  the  sub- 
jects would,  if  examined,  be  found  to  be  mouth-breathers. 

In  describing  a  case  of  diphtheria  (p.  368),  I  have  noted  that  a  peculiarity  of  respira- 
tion, which  I  have  called  '  Cheyne-Stokes,'  was  observed  on  three  nights  of  the  acute 
stage,  while  the  child  was  asleep,  and  I  have  further  mentioned  that  this  symptom  was 
only  apparent  when  the  nasal  cavities  were  blocked,  and  was  relieved  by  treatment 
directed  to  a  re-establishment  of  the  normal  nasal  breathing. 

Of  course,  it  is  possible  that  cardiac  depression,  a  result  of  the  toxic  influence  of  the 
disease,  may  have  been  more  or  less  responsible,  but  cardiac  symptoms  were  very  slight 
in  this  case,  and  it  has  since  been  pointed  out  to  me  that  the  disturbance  in  the.  rhythm  of 
breathing  in  this  case,  as  well  as  in  Laryngismus  Stridulus,  is  not  so  much  of  the  nature 
of '  Cheyne-Stokes,'  which  consists  of  alternating  periods  of  dyspnoea,  with  prolonged 
and  varying  intervals  of  apnoea,  as  of  that  of  '  Biot,'  which  consists  of  brief  and  regular 
intermissions  of  apnoea,  the  respiratory  movements  in  the  intervals  being  unexaggerated. 

Buccal  respiration  due  to  the  presence  of  adenoids,  if  marked 
and  long-continued,  and  especially  when  the  faucial  tonsils  are 
also  enlarged,  may  give  rise  to  serious  facial  and  thoracic  de- 
formity, even  in  cases  in  which  the  functions  of  the  voice  and 
hearing  have  not  been  considered  by  parents  and  guardians 
sufficiently  impaired  to  call  for  medical  advice.  In  many  cases  of 
deaf-mutism,  these  growths  are  found ;  and  although  their 
removal  may  offer  but  little  hope  of  restoring  the  hearing,  to  the 
extent  of  obviating  the  necessity  of  developing  the  speech  by  lip- 
reading  or  other  adjuvant  systems;  yet  clearance  of  the  naso- 
pharyngeal vault  will  be  found  to  be  followed  by  a  great 
improvement  in  general  strength  and  intelligence,  and  con- 
sequently by  a  more  ready  response  to  such  educational  methods, 
as  well  as  to  improvement  of  the  voice,  especially  in  respect  of 
the  appreciation  of  modulations,  and  inflections  of  tone,  so  con- 
spicuously absent  in  the  speech  of  most  deaf-mutes.  It  should 
therefore   be   considered    as   an    essential  preliminary  to  the 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL.  641 


educational  treatment  of  all  these  cases.  In  almost  all  cases  of 
high-arched  and  cleft  palates  in  children,  post-nasal  overgrowths 
are  to  be  found,  but  opinion  is  still  divided  as  to  their  inter- 
dependence. I  have  but  little  doubt  that  their  removal  should 
be  made  a  preliminary  to  any  operation,  done  for  the  purpose  of 
closing  a  cleft  palate,  and  this,  not  only  with  a  view  of  improving 
the  disagreeable  voice  so  characteristic  of  this  condition,  even 
where  an  operation  has  been  successful  in  uniting  the  cleft,  but 
also  for  improving  the  chances  of  success  of  the  operation  in 
this  direction.  It  is  probable  also,  as  suggested  by  Spicer,  that 
the  tendency  to  dental  caries  in  these  subjects  is  in  some  way 
connected  with  mouth-breathing,  a  point  worthy  of  further  observa- 
tion at  the  hands  of  our  dental  confreres.  The  tendency  of  lym- 
phoid hypertrophies  to  atrophy  after  the  twenty-fifth  year  should 
be  no  reason  for  putting  off  the  operation  in  young  adults,  because 
many  of  the  symptoms,  such  as  deafness,  facial  and  thoracic  de- 
formity, faulty  articulation  and  confirmed  snoring,  may  in  the 
meantime  become  irremediably  established. 

Since  the  last  edition,  I  have  recorded  two  cases  in  which 
persistent  recurrence  of  laryngeal  neoplasms  in  children  had 
been  stopped  after  recognition  and  removal  of  adenoids.  It 
appears  reasonable  to  suppose  that  these  growths  may  be  respon- 
sible for  much  infantile  laryngitis,  to  be  followed  in  a  certain 
proportion  of  cases  by  the  development  of  neoplastic  tissue,  and 
the  hint  is  at  least  worthy  of  remembrance  in  the  future. 

And  here  the  writer  may  be  allowed  to  quote  the  reply  which 
he  made  to  a  very  pertinent  question  recently  asked  by  Mr. 
Edmund  Owen  at  the  Harveian  Society,  where  the  subject  of 
adenoids  was  under  discussion  on  the  initiative  of  that  surgeon. 
'  How  did  children  get  on  before  the  discovery  by  Meyer  of 
adenoid  vegetations,  as  a  cause  of  deafness  ?'  and  it  might  have 
been  added  of  the  other  results  of  these  hypertrophies.  The 
answer  was  '  that  formerly  in  those  cases  in  which  there  were 
enlarged  tonsils,  removal  did  exert  a  certain,  and  in  some  cases 
a  remarkable,  improvement  in  the  hearing.  But  as  in  many 
other  instances  in  surgery,  with  our  later  knowledge  of  the 
subject  we  should  not  now  be  satisfied  with  the  results  we  then 
obtained,  for  though  doubtless  cases  might  be  seen,  in  which 
there  were  adenoids  without  enlargement  of  the  tonsils,  yet  in  at 
least  ninety  per  cent,  of  the  latter  condition  the  former  also 
existed,  and  therefore  it  had  become  with  the  speaker  a  fixed 
rule  always  in  such  cases,  to  search  for  adenoids,  and  if  present 
to  remove  them  as  an  essential  part  of  the  operation  of  ordinary 

41 


642 


DISEASES  OF  THE  THROAT  AND  NOSE. 


tonsillotomy.  Of  course,  there  are  still  surgeons  living  who 
object  to  remove  adenoids,  as  there  are  even  yet  some  who  depre- 
cate removal  of  the  faucial  tonsils,  on  the  grounds  that  children 
"  will  grow  out  of  them  ;"  but  it  ought  to  be  remembered  that  even 
if  hypertrophies  do  become  reduced  with  advance  of  age,  the 
subjects  have  in  the  meantime  "  grown  into  their  symptoms," 
and  that  one  sees  every  day,  cases  of  deafness  and  other  results 
of  adenoids  in  adults  and  in  middle  life  which  might  have  been 
prevented,  had  knowledge  been  more  perfect  when  the  patients 
were  children.' 

The  Diagnosis  is  usually  easy  from  an  inspection  of  the  face 
and  throat.  The  open  mouth,  flattened  cheeks,  collapsed  and 
dimpled  alse,  widened  bridge  and  pufly  oedematous  root  of  the 
nose,  down-drawn  inner  canthi,  and  the  naso-labial  fold,  have 
been  already  more  than  once  alluded  to.  The  veins  about  the 
root  of  the  nose,  forehead,  and  inner  canthi  are  sometimes  full 
and  prominent,  but  the  transverse  nasal  arch,  described  by  Spicer, 
is,  according  to  my  experience,  decidedly  infrequent  except  in 
earliest  infancy ;  when  present,  it  no  doubt  usually  points  to 
obstructions  in  the  nose,  cranium,  or  orbit. 

On  examination  of  the  back  of  the  mouth,  the  faucial  tonsils 
are  often  hypertrophied ;  masses  of  lymphoid  tissue  can  usually 
be  seen  at  the  back  of  the  pharynx,  especially  if  the  paretic 
palate  be  displaced  forwards  and  upwards  with  Frankel's  depressor 
or  by  a  hook.  It  is  sometimes  necessary  to  spray  or  brush  away 
the  mucous  accumulations  which  often  obscure  the  view,  and 
constitute  a  diagnostic  evidence  of  import.  The  paretic  and 
thickened  condition  of  the  palate  is  also  frequently  suggestive 
of  naso-pharyngeal  trouble.  When  the  faucial  tonsils  are  not 
enlarged,  there  is  seen,  in  addition  to  paresis,  a  want  of  definition 
of  the  anterior  and  posterior  pillars,  and  behind  the  latter, 
lymphoid  hypertrophies  along  the  salpingo-pharyngeal  fold ; 
these  are  sometimes  present  in  post-nasal  catarrhal  conditions 
in  adults,  and  have  been  previously  alluded  to  as  pharyngitis 
hypertrophica  lateralis.  Existence  in  children  of  the  conditions 
which  in  the  adult  would  be  recognised  as  granular  pharyngitis 
or  hypertrophic  rhinitis,  are  almost  certain  indications  of  adenoids. 

The  appearance  of  adenoids  on  ocular  inspection  is  well 
demonstrated  in  Fig.  5,  Plate  II.,  and  in  Fig.  41,  Plate  V. 

The  case  was  that  of  a  young  lady,  aged  17,  of  handsome  personal  appearance,  except 
that  she  exhibited  the  physiognomy  characteristic  of  the  habitual  mouth-breather.  She 
came  under  notice  in  October,  1877,  suffering  in  an  extreme  degree  from  every  symptom 
which  has  been  described  as  characteristic  of  the  malady  under  consideration.  On  the  2nd. 
of  November,  Mr.  Clover  administering  chloroform,  I  destroyed  all  the  hypertrophied 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL. 


643 


tissues  at  the  vault  of  the  pharynx,  having  previously  reduced  a  supplementary  hyperplasia 
which  existed  on  each  side  of  the  vomer.  There  was  but  little  blood  lost,  very  slight 
after-pain  or  discharge,  and  in  a  week  the  patient  could  blow  out  an  ordinary  wooden 
match  from  either  nostril  at  a  distance  of  eighteen  inches.  She  became  able  to  breathe 
with  mouth  closed,  while  even  in  sleep  the  mouth  was  kept  but  very  slightly  open,  and 
respiration,  both  waking  and  sleeping,  was  noiseless. 

All  doubt,  however,  as  to  the  existence  or  not  of  overgrowth  of 
the  pharyngeal  tonsil  can  be  set  at  rest  by  a  gentle  and  careful 
digital  examination.  Students  may  do  much  damage  by  explora- 
tions of  the  post-nasal  region,  unless  they  have  made  themselves 
practically  acquainted  with  the  topography  of  the  parts  by  re- 
peated digital  examinations  on  the  cadaver. 

It  must  be  remembered  that  a  soft  pad  or  cushion,  with 
possibly  longitudinal  ridges,  is  normally  present  in  children,  and 
even  in  young  adults ;  unless  this  cushion  is  thick,  firm  and 
large,  so  as  to  encroach  much  on  the  space  of  the  pharyngeal 
vault,  and  to  obscure  the  sharp  upper  margins  of  the  posterior 
narial  openings  or  approaches  to  the  Eustachian  orifices,  the 
diagnosis  of  hypertrophy  is  incorrect ;  but  when  the  naso- 
pharynx is  found  blocked  by  a  mass  of  soft,  or  occasionally 
tough,  stalactite  vegetations,  ranging  in  clusters  from  the  vault 
and  posterior  lateral  walls,  and  feeling  to  the  touch  like  '  a  bag  of 
worms  or  currants,'  or  occasionally  having  a  more  friable  con- 
sistence, then  there  can  rarely  be  a  moment's  doubt  in  the  mind 
of  even  the  merest  tyro. 

As  a  preliminary  to  all  explorations  or  examinations  on  the 
living  subject  the  metacarpo-phalangeal  joint  and  digit  of  the 
index-finger  should  be  protected  by  a  guard,  extemporized  or 
otherwise.  Hovell's  contrivance  (Fig.  CCXXIV.),  made  of  soft 
rubber  tubing,  is  most  simple  and  efficient,  and  I  now  employ  it 
by  preference  to  the  lobster-claw  jointed  metal  protector  (Fig. 
CCXXIII.)  which  I  formerly  advocated.  There  is  one  practical 
point  in  the  use  of  guards  which  I  have  often  found  it  necessary 
to  insist  on,  namely,  that  in  order  to  avoid  being  bitten  on  with- 
drawing the  finger,  the  guard  should  be  left  between  the  teeth. 

In  making  a  digital  examination  of  the  naso-pharynx,  I 
always  direct  my  pupils  and  clinical  assistants  to  feel  for  the 
free,  hinder  border  of  the  vomer ;  the  posterior  nares  can  then  be 
explored  for  polypi  and  hypertrophies,  etc. ;  the  position  of  the 
Eustachian  opening,  with  its  cartilaginous  cushion,  should  then 
be  made  out  laterally ;  and  lastly,  the  roof  can  be  explored  from 
the  septum  backwards.  The  .growths  will  rarely  be  found  actually 
touching  the  tubal  prominence,  but  are  most  abundant  on  the  roof 
and  posterior  wall  of  the  naso-pharynx,  and  frequently  obliterate 
the  fossae  of  Rosenmiiller. 


644 


DISEASES  OF  THE  THROAT  AND  NOSE. 


Wounding  of  the  soft  palate  and  any  bleeding  more  than 
the  slight  hcemorrhagic  staining  of  the  finger,  which  is  in  itself 
an  evidence  of  the  presence  of  soft  hypertrophy,  indicates  clumsy 
manipulation,  unless,  indeed,  the  patient  is  unusually  fractious. 
It  need  not  be  said  that  it  is  always  desirable,  and  sometimes 


Fig.  CCXXI  1 1. —Author's  Fincer  Guard,  with  (a)  Movable  Curette,  and 
{d)  Movable  Sharp  Spoon. 

almost  imperative,  to  reduce  to  a  minimum  the  terrors  of  these 
procedures,  both  for  the  sake  of  the  child  and  its  parents.  Having 
satisfied  myself  by  other  signs  that  the  abnormality  exists,  I  now 
make  the  rule,  previously  warning  the  parents  of  the  probable 
presence  of  the  obstruction,  and  the  desirability  of  its  removal. 


Fig.  CCXXIV.— Hovell's  Soft  Rubber  Finger  Guard. 
The  shield  is  made  to  cover  the  finger  entirely  between  the  knuckle  (a),  and  first 
phalangeal  articulation  {d),  and  to  project  beyond  each  of  these  points  both  forwards  and 
backwards  on  the  dorsal  surface  ;  but  the  tube  is  split  at  each  side  (r),  so  as  to  allow  free 
flexion  of  the  finger  at  the  angle. 


Fig.  CCXXV. — Schutz's  Antero-posterior  Forceps  for  Adenoid  Growths. 
to  give  an  anaesthetic  such  as  nitrous  oxide,  and  then  to  finish 
the  diagnostic  examination  with  the  finger  by  a  curative  scraping, 
thus  averting  the  pain  and  fright  of  a  second  operation. 

Although  I  am  a  strong  advocate,  both  in  precept  and  practice, 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL.  645 


of  examinations  by  posterior  rliinoscopy  in  all  cases  where  this 
is  practicable,  I  am  bound  to  admit  that  the  procedure  is  often 
impossible  in  children  with  naso-pharyngeal  obstructions  and 
enlarged  tonsils,  even  with  the  aid  of  the  various  contrivances 
for  pulling  forward  the  soft  palate.  It  is,  moreover,  scarcely 
worth  the  trouble  of  attempting,  as  such  a  step  is  unnecessary 
when  the  other  symptoms  previously  detailed  are  present. 

Treatment. — The  only  certain  method  of  relieving  symptoms 
caused  by  hypertrophy  of  the  pharyngeal  tonsil  is  to  remove  the 
exuberant  and  obstructing  overgrowth.  This  can  be  done  by 
means  of  curved  forceps,  opening  laterally  or  antero-posteriorly, 
passed  into  the  naso-pharynx  by  the  mouth.  Of  these  I  prefer 
Schutz's  pattern  (Fig.  CCXXV.),  which  nip  the  glandular  tissue 
from  before  backwards ;  but  Loewenberg's,  or  one  of  the  many 
modifications  of  the  same,  which  open  laterally,  are  much  used. 
By  these  instruments  the  growths  are  removed  piecemeal,  some 
four  to  twelve  insertions  of  the  instrument  being  necessary.  The 
Hartmann's  pattern  is  the  best.  Curetting  through  the  nose  is  an 
operation  that  can  also  be  fairly  efficiently  performed  by  means  of  a 
curette  with  a  naso-pharyngeal  curve  inserted  through  the  mouth  ; 
but  it  is  a  painful  and  generally  unsatisfactory  procedure,  and  the 
same  maybe  said  of  snaring  the  growths  through  the  nose  or  mouth. 

I  condemn  reduction  by  the  galvano-caustic  loop  or  electrode  in 
children,  because  this  method,  even  in  skilled  hands,  not  in- 
frequently leads  to  acute  inflammation  of  the  Eustachian  tube 
and  tympanum.  The  same  may  also  occur  from  traumatism  of 
the  tubal  orifice,  as  the  result  of  unskilful  manipulations  of  the 
forcep  or  curette.  A  thimble-shaped  curette  worn  on  the  index- 
finger  was  much  in  vogue  a  few  years  ago,  and  I  have  occa- 
sionally employed  it,  but  for  some  time  I  have  discarded  all 
instruments  in  favour  of  the  finger-nail  of  the  index-finger 
previously  dipped  into  absolute  alcohol,  and  introduced  into  the 
naso-pharynx  for  the  purpose  of  a  digital  examination  ;  by 
energetic  nail-scraping  I  can  insure  a  more  thorough  removal  of 
the  whole  gland  than  by  any  instrument  unaided  by  digital  touch, 
an  important  point  considering  the  tendency  to  recurrence  in  a 
certain,  though  as  yet  undetermined,  proportion  of  cases.  Some 
authors  state  that  they  commence  with  the  forceps  or  curette, 
but  that  they  have  to  finish  up  with  the  finger-nail.  Those  who  pos- 
sess the  tactus  evuditus  will,  however,  prefer  to  use  the  nail  in  the 
first  instance,  and  save  both  time  and  trouble  by  discarding  more 
or  less  clumsy  instrumental  substitutes,  which  have  to  be  applied 
in  the  dark.  In  this  practice  I  have  ascertained  that  I  am 
supported  by  Mr.  Field,  Mr.  Matheson,  and  other  leading  aurists, 


646 


DISEASES  OF  THE  THROAT  AND  NOSE. 


whose  preference  for  the  finger-nail  is  probably  due  to  know- 
ledge of  the  fact  that  only  by  this  means  is  injury  of  the  Eustachian 
orifice  certainly  insured  against.  The  finger-7tail  procedure  is 
particularly  successful  in  the  case  of  children  tip  to  seven  years  of  age, 
after  which  I  employ  first  a  curette,  either  the  antero-posterior 
of  Gottstein  (Fig.  CCXXV.a),  of  Hartmann  (Fig.  CCXXV.6), 
or  the  lateral,  but  I  rarely  use  the  forceps  at  ail.  However,  in 
these  matters,  it  is  best  to  be  eclectic  and  to  vary  the  pro- 
cedure as  circumstances  may  dictate. 

The  operation,  though  simple  in  the  sense  that  no  complex 
instruments  are  necessary,  is  not  without  dangerous  complica- 
tions in  other  than  competent  hands. 

On  the  vexed  question  whether  an  anaesthetic  should  or  should 
not  be  used  for  what  is  often  described  as  a  simple  operation,  I 
desire  to  speak  in  no  uncertain  tone.  In  private  practice  I  never 
operate  without  one  except  in  the  case  of  individuals  above 


Figs.  CCXXV.a  and  CCXXV./--— Naso-pharyngeal  Curettes. 


These  illustrations  are  not  drawn  in  proportion,  both  the  shank  and  the  handle  being 
represented  as  too  short. 

puberty,  when  cocaine  is  sometimes  preferred  and  found  sufficient ; 
nevertheless,  in  children  and  in  nervous  subjects  I  am  usually  able 
to  do  all  that  is  necessary  under  the  influence  of  nitrous  oxide. 
With  such  short  anaesthesia  I  have  many  hundreds  of  times 
performed  double  tonsillotomy  and  thorough  digital  scarification, 
or  curetting,  of  the  naso-pharynx  at  one  operation.  Ether,  which 
is  sometimes  employed  in  my  practice  as  supplementary  to  gas, 
is  no  doubt  a  less  dangerous  agent  than  chloroform,  but  it  generally 
stimulates  the  outpouring  of  an  inconvenient  excess  of  frothy 
saliva ;  it  also  increases  the  tendency  to  haemorrhage  ;  and  the 
liability  of  blood  entering  the  lungs  is  present  whichever  of  these 
two  agents  is  employed  ;  the  slow  recovery  from  chloroform 
narcosis  increases  the  possibility  of  this  contingency  in  the  case 
of  that  anaesthetic.  Where  chloroform  or  ether  is  employed  it 
should  never  be  pushed  beyond  the  second  stage. 


NASO-PHARYNGEAL  NEW 


GROWTHS. 


647 


The  position  of  the  patient  which  is  observed  in  my  practice  is 
that  of  sitting,  the  same  as  for  tonsillotomy  (p.  256)  ;  after  removal 
of  the  faucial  tonsils  the  head  is  pushed  slightly  forward,  so  as  to 
prevent  any  chance  of  blood  running  back  into  the  trachea ;  but 
even  if  that  occurs,  recovery  from  narcosis  under  gas  is  so  rapid 
that  no  danger  on  this  score  need  be  anticipated.  I  can  only  say 
that  of  the  thousands  of  cases  in  my  own  practice  and  that  of  my 
colleagues  who  give  the  same  anaesthetic,  with  the  patient  in  the 
sitting  position,  no  death  has  occurred.  On  the  other  hand  I  was 
shocked,  when,  in  the  discussion  to  which  I  have  already  alluded, 
three  speakers  gave  experience  of  fatal  issues,  four  different  cases 
in  all  being  recorded. 

There  is  generally  some  bleeding,  but  this  is  seldom  of  serious 
extent.  Anterior  nasal  syringing  (Fig.  LXXIV.)  or  posterior 
nasal  douching  (Fig.  LXXII.)  with  simple  alkaline  solutions 
(Form.  78)  may  be  required  for  a  few  days  or  weeks,  but  now- 
adays it  is  considered  safer  to  leave  the  parts  alone  for  at  least  forty- 
eight  hours,  the  better  to  prevent  the  risk  of  median  otitis. 

An  important  question  is  that  of  the  recurrence  of  these  growths, 
and  the  necessity  for  a  repetition  of  surgical  measures,  the  one, 
however,  not  being  entirely  dependent  on  the  other.  Answering 
the  last  point  first,  a  second  operation,  due  to  an  imperfect  at- 
tempt at  removal,  is  less  likely  to  follow  the  use  of  the  finger-nail 
or  curette  than  the  use  of  the  forceps  alone ;  in  any  case  digital 
examination  should  always  be  made  to  assure  the  surgeon  of  a 
resultant  clear  chamber. 

Nevertheless,  if  but  a  small  fragment  be  left,  it  often  happens 
that  the  inflammation  consequent  on  the  operation  may  lead  to 
a  rapid  hypertrophy  of  this  remnant.  In  many  of  these  cases 
this  apparently  new  overgrowth  will  be  almost  as  quickly  absorbed, 
and  I  am  therefore  not  in  a  hurry  to  perform  a  second  scraping, 
which  may  be  necessary  in  the  hands  of  even  the  best  surgeons; 
but  the  necessity  of  more  frequent  repetition  is  seldom  called  for 
unless  the  previous  ones  have  been  incomplete  from  want  of  skill 
or  experience,  or  where  more  confidence  has  been  placed  in  the 
forceps  than  in  the  finger.  In  many  cases  in  which  free  nasal 
respiration  is  not  established  after  the  operation  there  will  be 
found  a  persistent  vascular  hypertrophy  of  the  posterior  portion 
of  the  inferior  turbinal,  or  some  other  intra-nasal  cause  of 
obstruction,  such  as  a  deviated  septum  or  a  spur,  but  as  a  rule 
both  the  turbinal  engorgement  representing  the  quasi-hypertrophic 
rhinitis  as  well  as  the  granular  pharyngitis  previously  mentioned 
as  concomitants  of  adenoids  will  disappear  with  the  re-establish- 
ment of  free  nasal  respiration. 


648 


DISEASES  OE  THE  THROAT  AND  NOSE. 


Many  cases  of  deafness  due  to  impeded  Eustachian  ventilation 
are  likewise  cured  without  further  direct  measures  for  improving 
the  patency  of  the  tube,  but  in  some  a  course  of  Politzer  inflation 
may  be  required.  Such  treatment  should  in  no  case  be  com- 
menced within  a  fortnight  of  the  removal  of  the  growths. 

When  mouth-breathing  continues  during  sleep,  with  persistence 
of  the  objectionable  habit  of  snoring,  the  nasal  breathway  being 
free,  I  advise  that  the  lower  jaw  should  be  held  up  by  a  lightly- 
tied  bandage  or  other  support,  such  as  Guye's  '  Contra-respirator  ' 
or  *  Anti-snorer,'  worn  under  the  chin  and  over  the  head,  for  a 
few  weeks  or  until  the  habit  is  cured.  Where  there  is  paralysis 
from  disease  of  the  dilator  muscles  of  the  nostrils,  I  advise 
gymnastic  exercise  in  the  shape  of  forcible  nasal  in-  and  ex-hala- 
tions to  restore  their  action. 

In  cases  of  stammering  and  defects  of  articulation,  the  removal 
of  the  impediment  to  the  action  of  the  soft  palate  will  have  a 
like  happy  result,  and  I  have  often  witnessed  the  circumstance 
that  children  the  subject  of  hesitancy  will  speak  without  impedi- 
ment for  a  day  or  two  after  I  have  operated,  but  relapse  is  almost 
invariable,  so  that  after-education  is  always  essential  for  restoring 
and  making  permanent,  functional  activity  in  the  long-disused,  or 
never  previously  exercised  muscles. 

The  question  is  often  asked  why  mere  tonsillotomy  in  the  period 
prior  to  the  recognition  of  the  importance  and  removal  of  adenoid 
growths  was  so  often  successful  in  relieving  the  symptoms  and 
results  of  naso-pharyngeal  obstruction  ?  The  answer  is  obvious. 
The  bleeding  and  relief  of  lymphatic  and  venous  tension  not  only 
results  in  some  subsidence  in  the  size  of  the  pharyngeal  and 
tubal  tonsils,  but  likewise,  in  young  children,  in  the  temporary 
abatement  of  erectile  tumefaction  in  the  nose.  The  relief,  how- 
ever, is  by  no  means  always  permanent ;  and  in  the  light  of  our 
later  knowledge  regarding  adenoids  it  is  almost  amazing  that 
the  results  of  simple  removal  of  enlarged  faucial.  tonsils  were 
formerly  so  generally  and  largely  beneficial.  Nowadays,  as  before 
stated,  I  never  perform  ordinary  tonsillotomy  without  a  supple- 
mentary digital  exammation  of  the  naso-pharynx,  to  be  immedi- 
ately followed,  then  and  there,  by  removal  of  any  existing 
adenoids.  The  results  of  omission  to  carry  out  this  routine  per- 
formance have  frequently  come  under  my  notice,  albeit  the 
faucial  tonsillotomy  has  been  well  performed  by  very  capable 
practitioners.  In  all  a  naso-pharyngeal  curetting  has  been 
followed  by  completion  of  the  good  effect  of  the  previous 
operation. 


NASO-PHARYNGEAL  NEW  GROWTHS. 


649 


NASO-PHARYNGEAL  NEW  (iROWTHS. 

Under  this  heading  are  included  such  tumours  as  myxomata, 
fibromata,  sarcomata  and  carcinomata.  Of  these,  fibromata  are  by 
far  the  most  common,  while  the  more  malignant  tumours  are 
exceedingly  rare.  So-called  '  adenoid  growths  '  are  not  true  new 
growths,  but  really  hypertrophies,  as  previously  explained,  and 
are  therefore  not  properly  included  in  this  section. 

Teratomata  merit  but  a  passing  word,  since  they  are  of  such 
rarity  as  to  be  viewed  mainly  as  pathological  curiosities. 

Myxomata  are  often  seen  in  the  naso-pharynx,  but  they  nearly 
always  spring  from  the  mucous  membrane  of  the  nasal  passages 
proper  (vide  Fig.  CCXXL,  p.  614);  their  pathology,  symptoms, 
and  treatment  has  been  detailed  in  the  previous  chapter. 

Fibromata  differ  in  no  way  from  true  nasal  growths  of  similar 
structure ;  they  spring  from  the  periosteum  or  connective-tissue 
of  the  vault  of  the  pharynx.  They  grow  and  encroach  by  pressure 
on  neighbouring  areas  much  more  rapidly  in  the  young  than  in 
adults.  In  addition  to  the  usual  symptoms  of  post-nasal  obstruc- 
tion they  are  accompanied  by  pain,  haemorrhage,  and  other 
symptoms  characteristic  of  true  nasal  fibromata.  Headache  and 
aprosexia  are  always  marked  when  the  growths  attain  any  size. 

Diagnosis  is  easy  on  account  of  the  pain,  bleeding  and  con- 
sistence of  the  tumours.  They  are  usually  attached  by  a  broad 
base,  and  are  only  successfully  treated  by  bold  operative  measures. 

These  consist  during  early  stages  in  removal  of  the  mass  of 
the  tumour  or  tumours  by  evulsion  with  forceps  or  strong  and 
suitably  curved  uterine  ecraseur,  the  latter  being  passed  and 
adjusted  behind  the  soft  palate.  In  some  instances,  a  strong 
snare  is  best  passed  through  the  nose.  The  base  requires 
energetic  eradicating  by  a  thorough  curetting,  and  the  destruc- 
tion of  the  whole  of  the  morbid  area  from  which  the  neoplasm 
springs  by  galvanic  or  other  form  of  cautery.  These  operations 
are  usually  attended  with  considerable  haemorrhage,  and  although 
never  alarming  in  the  few  cases  I  have  seen,  serious  loss  of  blood 
has  occurred  in  several  reported  instances.  When  the  area  of 
attachment  is  very  large,  and  where  the  growth  has  encroached 
on  the  base  of  the  skull,  or  pterygoid  region.  Rouge's  or  Ollier's 
or  some  other  external  operation  may  be  necessary. 

Interference  by  operation  with  sarcomata  and  carcinomata  in 
this  region,  though  justifiable  in  some  instances,  has  not  been,  up 
to  the  present,  encouraging.  Electrolysis  in  the  sarcomatous  form 
has  been  employed  by  me  successfully  in  two  cases ;  but  I  failed 
with  the  same  treatment  in  two  others. 


CHAPTER  XXVI. 


AURAL   MALADIES   ASSOCIATED  WITH   NASO- PHARYNGEAL 

DISEASE. 

PART  I.— HOW  TO  EXAMINE  AN  AURAL  CASE. 

INSTRUMENTS  NECESSARY. 

1.  Frontal  mirror,  as  for  laryngoscopy,  or  preferably  one  of  less  focal  distance,  and 
laryngeal  mirror  for  rhinoscopy  (p.  45). 

2.  Anterior  nasal  speculum  (p.  78). 

3.  Set  of  aural  specula,  Gruber's  or  Keene's,  or  Brunton's  auriscope. 

4.  Politzer  bag,  with  nozzle  to  fit  catheter,  and  soft  rubber  nasal  piece. 

5.  Auscultation  or  diagnostic  tube,  usually  but  improperly  called  Otoscope. 

6.  Tuning-fork,  tuned  to  middle  C,  and  clamped  to  damp  overtones.  That  known  as 
Gardiner  Brown's  is  the  best. 

7.  Eustachian  catheter,  two  or  three  sizes. 

8.  Siegle's  pneumatic  speculum,  fitted  with  author's  exhausting  bag. 

Before  treating  generally  on  deafness  associated  with  diseases 
of  the  throat,  it  will  be  useful  to  shortly  explain  the  significance 
of  the  various  steps  to  be  taken  in  the  diagnosis  of  a  case  of  aural 
disease,  so  as  to  assist  in  overcoming  at  least  some  of  the  diffi- 
culties. These  explanations,  in  which  there  is  nothing  very  new, 
will  not,  of  course,  be  needed  by  experts,  but  they  will,  I  trust, 
be  regarded  as  acceptable  to  the  general  practitioner,  who,  so 
frequently  seeing  cases  of  recent  date,  has  many  more  chances  of 
doing  good  than  the  specialist,  to  whom  they  are  rarety  brought 
until  the  time  for  cure,  or  even  it  may  be  for  relief,  has  passed 
away.  I  am  the  more  induced  to  believe  that  this  trust  has  good 
foundation,  because  it  is  a  very  general  complaint  that  treatises 
on  the  ear  either  assume  too  much  knowledge  from  the  reader,  or 
are  so  overladen  with  theory  and  speculations  as  to  be  too  lengthy 
for  the  busy  practitioner. 

Investigation  of  the  cause  of  a  middle  or  internal  ear  affection 
is  a  much  more  complex  process  than  in  the  case  of  trouble 
affecting,  say,  the  voice  or  sight ;  inasmuch  as  in  the  first  place, 
while  the  laryngoscope  or  ophthalm.oscope  brings  the  observer 
face  to  face  with  an  exact  image  of  the  whole  vocal  or  optical 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  651 


apparatus,  the  aural  speculum  enables  us,  in  but  too  many  cases, 
only  to  see  mere  signs  from  which  we  must  draw  deductions — 
more  or  less  accurate  according  to  our  experience — of  the  condi- 
tions indicated  thereby.  Further,  while  it  is  easy  to  test  the 
voice,  by  means  of  the  musical  scale,  so  as  to  discover  the  exact 
note  at  fault,  or  to  gauge  the  defects  of  sight,  by  means  of  glasses, 
with  mathematical  precision,  we  have  at  present  no  equivalent 
standard  of  exact  comparison  by  which  we  can  accurately  ascer- 
tain the  amount  and  quality  of  deafness.  Lastly,  whereas  defect 
of  sight  or  loss  of  voice  is  quickly  noticed  and  relief  for  it  is  early 
sought  by  the  patient,  loss  of  hearing  power  is  frequently  so  gradual 
that  it  is  not  heeded  until  the  history  of  the  case  and  of  subjective 
symptoms  is  half  forgotten,  while  the  physical  conditions  have 
undergone  such  an  amount  of  pathological  change  as  to  render 
diagnosis  difficult,  and  a  complete  restoration  of  hearing  im- 
probable. 

A.  Functional  and  Subjective  Symptoms. — Setting  aside 
affections  of  the  external  ear,  aural  patients  come  under  observa- 
tion on  account  of  Deafness,  Discharge  from  one  or  both  ears. 
Pain,  Tinnitus,  or  Vertigo.  It  is  very  rare  for  any  of  the  last 
fous-.'  conditions  to  exist  with  perfect  hearing,  and  this,  the  special 
function  of  the  ear,  must  in  all  cases  be  tested  by  the  three  methods 
in  use.  Conversation,  Watch,  and  Tuning-fork,  of  which  the  first 
two  are  convenient,  but  by  no  meims  exact. 

I.  Hearing  Power. — Conversation. — This  test  will  be  employed 
in  the  first  remarks  addressed  to  the  patient,  and  during  the  time 
of  taking  the  history,  which  should  always  be  done  on  a  systematized 
plan.  All  deaf  persons  complain  vvith  some  justice  that  speakers 
either  mumble  or  shout.  Let  enunciation  therefore  be  distinct, 
and  let  the  voice  be  graduated  from  rather  below  ordinary  con- 
versational power  upwards,  at  the  same  time  approaching  nearer 
to  the  patient's  ear  until  he  hears  what  is  said.  Conversation 
may  be  divided  into  low,  ordinary  and  shouting.  If  low  conver- 
sational power  is  heard,  and  at  a  moderate  distance,  the  hearing 
may  be  tested  by  whispers,  of  which  it  is  also  easy  to  make  two  or 
three  grades — low,  ordinary,  and  loud.  To  these  tests  that  of 
distance  can  be  added,  and  one's  consulting-room  can  be  marked 
out  to  more  or  less  accurately  indicate  differences  in  this  respect. 
If  the  patient  is  observed  to  watch  the  lips  of  the  speaker, 
direct  him  to  close  his  eyes,  and  then  observe  whether  he  hears 
equally  well.  Ascertain  whether  he  hears  better  when  only  one 
person  is  speaking,  or  as  at  a  dance  or  dinner  where  there  is  con- 
fusion of  noise,  or  in  a  railway  train  or  carriage  where  there  is 


652 


DISEASES  OF  THE  THROAT  AND  NOSE. 


constant  vibration.  Also,  whether  in  Hstening  to  orchestral  music, 
or  to  choral  singing,  individual  tones  are  heard  distinctly,  or  arc 
blurred.  Finally,  ascertain  w^hether  the  patient  hears  his  own 
voice  as  unduly  loud,  and  whether  he  speaks  of  it  as  contained  in 
the  head,  and  continuing  to  resound  longer  than  normal. 

Watch. — This  test  should  always  be  employed,  especially  in  the 
case  of  children,  with  the  patient's  eyes  closed.  First  ascertain 
hearing-distance  of  the  test-watch  for  the  normal  ear.  It  may  be 
said,  for  general  purposes,  that  if  an  ordinary  (English-made)  man's 
watch  can  be  heard  at  a  distance  of  60  inches,  watch-hearing  power 
is  normal.  Let  60  then  be  represented  as  the  denominator  of 
the  fraction  indicating  the  number  of  inches  at  which  the  watch 
can  be  heard  in  health  ;  the  numerator,  the  actual  distance  in 
the  case  under  examination.  Thus  W.  -^J,  represents  that  the 
watch  is  heard  at  12  inches  ;  W.  f  J,  that  it  is  heard  at  normal  dis- 
tance. When  the  distance  is  less  than  an  inch,  the  addition  of  a 
cypher  to  the  denominator  would  express  the  quantity  in  tenths, 
thus  would  represent  half  an  inch,  though  I  personally  prefer 
to  write  it  as  -g-V?  etc.  For  unappreciable  distances,  I  employ 
the  signs  +  and  — .  Thus  W.  -|-  Contact,  W.  —  Contact,  W.  -f- 
Pressure,  W.  —  Pressure;  or  to  still  further  abbreviate,  W.  +  C, 
W.  —  C,  and  W.  +  P.,  W.  —  P.,  indicate  better  the  condition 
than  an  extension  of  the  fractional  system.  It  is  recommended  to 
place  the  watch,  in  the  first  instance,  at  normal  distance,  and 
then  to  allow  it  to  gradually  approach  towards  the  patient's  ear, 
to  the  point  at  which  it  will  be  heard,  or  to  pressure,  when  its 
audibility  or  inaudibility  will  be  demonstrated.  The  watch-test 
may  be  further  employed  as  indicating  whether  the  deafness  is 
due  to  obstruction  of  conducting  tube,  by  placing  the  watch 
behind  the  ear,  between  the  teeth,  or  on  the  vertex.  This  is, 
however,  more  accurately  done  by  the  tuning-fork.  The  latter  test 
is  reserved  till  later,  because  its  value  is  greatly  influenced  by  the 
existence  or  absence  of  other  symptoms  of  discharge,  pains,  etc. 

Politzer  has  invented  an  instrument  which  he  calls  the  A  coiuneter. 
There  is  no  necessity  to  describe  it  further  than  to  say  that  its 
inventor  claims  that  each  sample  is  constructed  so  carefully  that 
it  gives  a  tic-tac  of  exactly  the  same  quality  and  pitch,  and  therefore 
offers  a  more  uniform  standard  of  comparison  than  the  watch. 
The  only  disadvantage  I  have  found  in  it  is  that  the  sound  produced 
is  so  distinct  as  to  be  heard  at  too  long  distances  for  the  purposes 
of  everyday  diagnosis. 

II.  Discharge  from  the  Ears  may  be  largel}^  considered  as  a 
subjective  symptom,  seeing  that  it  is  often  only  reported  as 
existing  or  having  existed  ;  but  its  origin,  when  it  is  objectively 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  653 


present,  must  be  carefully  ascertained  by  means  of  optical  exami- 
nation of  meatus  and  membrane  (Nos.  V.  and  VI.,  Physical  Signs). 
Under  the  present  head  ascertain  the  patient's  own  account  of  it, 
especially  with  reference  to  its  date,  its  intermittence  or  constancy, 
and  its  fluid  and  odorous  characteristics. 

III.  Pain  is  in  all  diseases  an  important  symptom,  but  is  of 
especial  diagnostic  value  in  aural  cases.  It  may  indicate  only  an 
inflammation  or  furuncle  of  the  external  meatus,  or  it  may  point 
to  acute  inflammation  of  the  membrane  of  the  tympanum,  of  the 
tympanum  itself,  or  even  of  the  membranes  of  the  brain.  Pain 
almost  always  indicates  in  aural  disease  an  acute  inflammatory 
condition.  Pure  neuralgia  of  the  ears  is  of  rare  occurrence,  and 
in  the  generality  of  auditory  nerve  disease,  pain  is  conspicuously 
absent.  Pain  in  the  parietal  and  frontal  regions  in  children  suffer- 
ing from  otorrhoea,  is  an  important  symptom,  and  generally  points 
to  formation  or  retention  of  the  discharge  in  the  tympanum,  or 
extension  to  the  meninges  of  brain.  Pain  in  the  mastoid  indicates 
periosteal  inflammation  of  that  process,  or  suppuration  of  its  cells. 

IV.  Tinnitus,  or  noises  in  the  ear,  is  of  all  aural  sym_ptoms 
at  once  the  most  constant,  most  distressing,  and  too  frequently 
the  most  difficult  of  accurate  diagnosis  and  of  relief.  It  may 
be  said  briefly  that  (a)  humming,  buzzing,  or  booming  generally 
accompanies  presence  of  impacted  cerumen,  eczema,  foreign 
bodies,  or  parasites  ;  (6)  crackling  or  rustling,  deficiency  of  ceru- 
men ;  hairs  on  the  membrane  may  produce  sounds  as  of  an 
^olian  harp ;  (c)  bubbling  or  gurgling  indicates  mucous  or  other 
fluid  secretions  in  the  tympanum  ;  (d)  tidal  sounds,  contraction  of 
tensor  tympani  or  other  intrinsic  muscles  ;  {e)  constant  rushing, 
venous  congestion  of  labyrinth  ;  (/)  pulsating,  arterial  congestion. 
The  above  by  no  means  include  all  the  subjective  symptoms  com- 
plained of  by  the  patient.  There  is  the  hissing  or  singing  as  of  a 
tea-kettle,  the  music  as  of  a  sea-shell,  the  ringing  as  of  bells, 
and  the  actual  tunes  or  repetition  of  tunes  perpetually  dinning  in 
the  ears.  Almost  all  these  sounds  are  associated  vv^ith  chronic 
middle-ear  deafness,  and  depend  on  intra-tympanic  thickenings 
and  accumulations,  and  sometimes  on  muscular  changes  impairing 
the  powers  of  accommodation.  Lastly,  there  may  be  extra-aural 
anomalous  forms  of  tinnitus  which  will  require  due  investigation 
as  to  nature  and  cause.  Toynbee  and  Hinton  long  ago  recognised 
the  fact  that  some  of  these  cases  depended  on  dilatation  or 
aneurism  of  the  basilar  artery,  while  others  might  be  alleviated  by 
pressure  on  the  carotids.  Dundas  Grant  has  taken  advantage  ot 
this  circumstance  of  the  different  arterial  source  of  supply  to  the 
middle  and  internal  ear,  and  differentiates  the  origin  of  a  tinnitus 


654 


DISEASES  OF  THE  THROAT  AND  NOSE, 


by  observing  the  effect  produced  on  the  abnormal  sounds  by  com- 
pression of  the  carotid  or  of  the  vertebral  arteries  respectively. 

V.  Vertigo  is  a  symptom  of  very  grave  importance  ;  for, 
although  it  may  sometimes  be  present  in  so  simple  a  case  as  one 
of  impacted  cerumen,  it  generally  points  to  serious  mischief  in  thi; 
middle  or  internal  ear.  It  maybe  stated  almost  as  an  axiom  that  it  is 
due  to  inflammation  or  irritation,  direct  orreflex,  whatever  the  cause, 
of  the  labyrinth.  The  diseases  in  which  it  is  most  often  complained 
of  are  acute  aural  catarrh,  chronic  aural  catarrh,  chronic  purulent 
disease — the  secretion  being  retained — muscular  spasm,  primary 
labyrinthine  inflammations  and  congestion,  and  cerebral  tumours. 

VI.  and  VII.  All  symptoms  referable  to  the  nasal,  naso-pharyn- 
geal,  pharyngeal,  and  even  laryngeal  regions  are  to  be  carefully 
noted.    (See  '  Throat  Forms,'  p.  89.) 

Tuning-fork. — '  It  may  be  stated  as  an  axiom  that  the  normal 
ear  hears  the  tuning-fork  better  through  the  air  than  through  the 
bones  of  the  head  '  (Burnett).  If  a  tuning-fork  vibrating  on  the 
vertex  be  heard  better  on  the  deafer  side,  i.e.,  that  on  which  the 
watch  or  conversation  is  heard  least,  it  is  probable  that  this  is 
due  to  hindrance  offered  to  the  escape  of  sound-waves  by  closure 
of  Eustachian  tube  or  external  meatus  ;  that  is  to  say,  to  disease 
of  conducting-tube,  not  to  that  of  the  auditory  nerve.  This  pro- 
bability is  rendered  a  certainty,  if  on  gentle  closure  of  the  meatus 
by  the  finger  perception  of  the  fork's  vibrations  is  still  further 
increased.  It  has  been  remarked  that  excessive  pressure  of  the  finger 
on  the  external  meatus  will  lead  to  diminution  of  perception  of  the 
tuning-fork's  vibrations,  this  circumstance  being  explained  by  the 
consequent  temporary  induction  of  labyrinthine  congestion.  As  a 
rule,  the  ear  which  hears  better  the  tuning-fork  vibrating  on  the 
vertex,  may  be  considered  the  worse  ear ;  but  in  case  of  unequal 
paralysis  of  the  auditory  nerves,  the  converse  would  hold  good.  If 
the  nerve  be  paralyzed,  closure  of  the  auditory  canal  by  the  finger 
should  not  increase  the  hearing  of  the  fork's  vibrations  (Roosa). 

It  occasionally  occurs  that  patients  with  perforation  of  one 
membrane  will  hear  the  tuning-fork  at  the  meatus  better  on  that 
side ;  this  is  explained  by  the  increased  resonance  brought  about 
by  conversion  of  the  tympanum  and  auditory  canal  into  one  large 
air-chamber  ;  this  observation  only  holds  good  when,  however 
large  the  perforation,  the  support  of  the  malleus  is  intact. 

The  duration  at  which  the  vibrations  are  heard  when  the  fork  is 
in  contact  with  the  vertex,  teeth,  or  mastoid  process,  especially 
the  latter,  although  not  alluded  to  by  other  observers,  is  of  service 
in  my  own  practice  as  indicating  whether  there  is  lessened  power 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  655 


in  the  auditory  nerve,  which  is  so  often  to  be  noticed  in  long- 
standing catarrhal  cases.  If  the  observer,  w^ithdrawing  the  fork 
the  moment  the  patient  ceases  to  hear  the  vibrations,  place  it 
against  his  own  ear,  he  can  form  some  idea,  according  to  the 
time  he  continues  to  hear  it,  of  the  loss  of  nerve-power  on  the 
part  of  the  patient. 

The  following  are  the  directions  for  observation  and  the  conclu- 
sions to  be  drawn,  by  means  of  the  tuning-fork,  of  my  colleague 
Dundas  Grant,  who  has  paid  much  attention  to  this  important 
test,  and  has,  as  will  be  seen,  added  somewhat  to  our  knowledge 
on  the  subject  : 

'The  hearing  is  tested  by  means  of  the  tuning-fork,  by  noting  the  length  of  time  in 
seconds  it  is  heard  by  the  patient,  in  comparison  with  the  length  of  time  it  is  heard  by  a 
normally  hearing  person.  This  is  observed  both  when  the  fork  is  held  with  the  flat  of 
one  of  its  blades  near  the  meatus  but  not  touching,  and  when  the  fork  is  held  with  the  end 
of  its  shank  pressing  on  the  bones  of  the  head  ;  and  for  convenience,  the  mastoid 
process  of  the  ear  to  be  tested  is  selected.  By  the  former  method  the  "air-conduction  " 
(the  capacity  for  hearing  sounds  conveyed  by  means  of  the  tympanic  apparatus),  and  by 
the  latter  the  "bone-conduction"  (the  capacity  for  hearing  sounds  conducted  directly 
through  the  bones  of  the  head  to  the  internal  auditory  apparatus),  are  respectively  measured 
and  together  compared. 

*  It  will  be  noted  that  in  the  case  of  a  normal  ear  the  tuning-fork  is  heard  through  the 
air  longer  than  through  the  bones  (Rinne's  experiment),  the  difference  varying  with  different 
tuning-forks.  A  very  convenient  fork  for  general  use  is  the  one  devised  by  the  late  Mr. 
Gardiner  Brown,  tuned  to  the  middle  C.  A  specimen  may  advisably  be  selected 
which  is  heard  about  30  seconds  longer  at  the  meatus  than  _ 
on  the  mastoid.  For  extreme  cases  a  fork  sounding  for  a  much 
longer  time  (such  as  Politzer's)  is  necessary  ;  but  with  such  a  heavy 
fork  the  possibility  of  mistaking  vibrations  felt  for  vibrations  heard 
is  immensely  increased. 

'The  following  rule  for  the  use  of  the  tuning-fork  may  be 
accepted  as  the  most  practical  at  present  available  : 

*  I.  To  test  the  "air-conduction."  Set  the  tuning-fork  vibrating 
by  striking  it  on  the  knee  ;  place  it  with  the  flat  of  one  blade  close 
to  the  aperture  of  the  meatus  ;  direct  the  patient  to  indicate  the 
moment  it  stops  ;  then  place  it  opposite  your  own  (or  a  normal) 
car,  and  note  how  many  seconds  longer  it  is  heard.  The  number 
of  seconds  indicates  the  deficiency  of  hearing  on  the  patient's  part, 
and  should  be  noted  down  as,  say,  "  air-conduction,"  -  10". 

'  Should  it  not  be  heard  longer  by  the  normal  ear,  the  process  is 
to  be  repeated  in  the  reverse  order  (by  placing  it  first  to  your  own 
ear),  and  the  patient  credited  with,  say  -1-  10,  or  ±  o. 

'  Should  the  patient  not  hear  it  at  all,  the  fact  may  be  quasi- 
algebraically  expressed  by  the  formula  -  00  . 

'2.  To  test  the  "bone-conduction."  Apply  the  shank  of  the 
vibrating  tuning-fork  to  the  patient's  mastoid  ;  when  he  ceases  to 
hear  it,  apply  it  to  your  own  (supposed  normal),  and  note  how  many 
seconds  you  hear  it  longer  than  he  does.  The  number  obtained  is 
to  be  noted  down,  as,  say,  "bone-conduction,"  -  10". 

'  As  before  (and  this  is  by  far  the  most  frequent  event),  if 
you  do  not  hear  it  longer  than  the  patient,  reverse  the  process  ; 
and  if  he  hears  it  longer  than  you  do,  note  it  thus— say,  "  bone-conduction,"  +  10' 


Fig.  CCXXVI.— 

Gardiner  Brown's 

TUNING-FORK. 


6^6 


DISEASES  OF  THE  THROAT  AND  NOSE. 


*  Other  possible  results  will  easily  suggest  themselves,  as,  for  example  :  '*  bone-conduc- 
tion,";±:  o  ;  "  bone-conduction,"  -  oo . 

*  As  a  general  rule,  in  ear  afifections  dependent  on  naso-pharyngeal  diseases,  the  middle 
ear  is  alone  affected,  while  the  internal  auditory  apparatus  is  normal,  and  even  (ap- 
parently, at  least)  heightened  in  its  perceptive  activity.  We  therefore  find  the  "  air- 
conduction "  a  negative  quantity,  and  the  "bone-conduction"  a  positive.  In  a  great 
many  cases  the  decrease  of  *' air-conduction  "  (with  such  a  fork  as  has  been  recommended) 
turns  out  to  give  the  same  number  as  does  the  increase  in  "bone-conduction."  For 
instance,  "  air-conduction,"  -  lo"  ;  "  bone-conduction,"  +  lo". 

'  Space  will  not  permit  a  discussion  of  the  cause  of  this  phenomenon,  but  it  may  be 
roughly  stated  that  a  decrease  of  bone-conduction,  when  extreme,  points  (before  old  age) 
to  an  affection  of  the  internal  auditory  apparatus,  either  primary  or  secondary  to  middle- 
ear  disease  (spreading  in  cases  through  the  fenestra  ovalis,  and  involving  the  stapedial 
articulation). 

'The  two  ears  have  to  be  tested  separately,  both  at  the  meatus  ("air-conduction  ")  and 
on  the  mastoid  ("bone-conduction")  ;  and  the  results  in  a  supposed  case  might  be  con- 
veniently registered  as  in  the  forms  used  at  the  Central  London  Throat  and  Ear  Hospital 
— thus : 

At  Meatus    )      -  oo     _  lo 

[  R  - — 
On  Mastoid  S      rbo      +  lo 

*  In  cases  of  deafness  from  uncomplicated  impaction  of  cerumen,  it  is  commonly  found 
that  with  great  loss  of  "air-conduction"  the  "bone-conduction"  is  very  slightly,  or  not 
at  all,  increased — e.g. : 

At  Meatus  \  —20  -20 
On  Mastoid  )  +2 

•An  increase  of  "bone-conduction"  generally  indicates  the  coincidence  of  some 
degree  of  derangement  of  the  middle  ear. 

'  The  results  in  perforative  affections  of  the  tympanum  are  very  various  ;  as  a  rule 
there  is  some  increase  of  "  bone-conduction,"  but  not  at  all  in  proportion  to  the  decrease 
in  "  air-conduction." 

'  When  the  internal  ear  alone  is  affected,  the  absence  of  disease  of  the  conducting 
apparatus  is  shown  by  the  existence  of  the  normal  preponderance  of  "  air-conduction  " 
over  "bone-conduction." 

•Various  sources  of  fallacy  will  readily  suggest  themselves,  but  in  the  great  majority  ct 
cases  the  results  obtained  by  the  above  method  will  give  invaluable  information.' 

Tlie  foUowino^  diagnostic  table,  prepared  by  Grant  for  his 
lectures,  will  aid  in  the  detection  of  the  nature  and  seat  of  the 
disease  in  typical  cases  of  defect  of  hearing.  It  is  to  be  distinctly 
understood  that  it  is  prepared  not  as  an  actual  and  dogmatic  state- 
ment, but  rather  as  usefully  suggestive  of  the  direction  diagnosis 
may  take  on  an  intelligent  appreciation  of  subjective  evidences  ; 

The  patient  complains  of  deafness  (  =  dimmution  of  '  air-comluction  '). 
A.  Onset  sudden. 
Without  pain. 

a.  Bone-conduction  no7-mal  or  increased. 
I.  Slightly  or  inappreciably  increased. 

Cerumen. 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  657 


2.  Considerably  increased. 

Eustachian  catarrh. 
(3.  Bone-conduction  diminished  or  absent. 

1.  Without  sickness  or  giddiness. 

Secondary  syphilis  of  labyrinth. 

(Requiring  confirmation.) 

2.  With  sickness,  giddiness,  and  noises. 

Hcemorrhage  into  labyrinth. 

With  pain. 

1.  Fever  sh'ght,  and  no  discharge. 

Acute  catarrh  of  middle  ear. 

2.  Fever  high,  and  early  discharge. 

Acute  suppuration  of  middle  ear. 

B.  Onset  gradual. 

Without  PRESENT  suppurative  discharge. 

a.  Never  any  discharge. 

1.  Bone-conduction  diminished. 

Chronic  disease  of  internal  auditory  apparatus. 
(Or  senile  changes.) 

2.  Bone-conduction  increased. 

(1)  Commencing  with  much  tinnitus. 

Dry  middle-ear  catarrh . 

(2)  Commencing  with  naso-pharyngeal  catarrh,  and  with  moist 
sounds  on  auscultation. 

IVloist  middle-ear  catarrh, 
/3.  With  discharge  at  an  earlier  period. 

5.  With  present  perforation-sound  on  auscultation. 

Chronic  suppurative  catarrh^  with  permanent  perforation. 
2.  Without  perforation-sound. 

Chronic  suppurative  catarrh^  with  cicatrized  membrane. 

With  PRESENT  suppurative  discharge. 

1.  With  perforation-sound. 

Chronic  suppurative  catarrh  of  tympanum,  and  its  consequences. 

2.  Without  perforation-sound. 

Chronic  external  otitis  or  myringitis. 

B.  Physical  and  Objective  Signs. — I.  The  Buccal  Cavity 
(p.  56)  ;  II.  Pharynx  (p.  58)  ;  and  III.  Naso-Pharynx  (p.  83), 
must  all  be  inspected,  whether  before  or  after  the  ear  proper ; 
and  the  Auricle  (IV.)  for  malformations  and  outgrowths,  inflam- 
mations, or  cutaneous  manifestations.  In  the  Meatus  (V.)  we 
may  see  whether  an  otorrhoea  is  dependent  on  external  or  internal 
causes,  and  may  diagnose  the  presence  of  impacted  cerumen, 
foreign  bodies,  exostoses,  and  the  like. 

VI.  The  Membrana  Tympani  should  be  examined  with  refer- 
ence to  the  points  in  the  various  columns  of  the  case-form.  The 
appearance  of  its  normal  condition,  as  well  as  the  various  struc- 
tures usually  to  be  noted  on  ocular  inspection  with  the  speculum, 

42 


658 


DISEASES  OF  THE  THROAT  AND  NOSE. 


are  indicated  in  the  accompanying  illustration  Fig.  CCXXVIL). 
Colour  should  be  mother-of-pearl  grey,  with  just  a  similar  soft  lustre  ; 
though  the  tint  of  one  membrane  will  vary  in  tone  from  another, 
just  as  may  one  piece  of  mother-of-pearl  from  another.  There 
may  be  slight  pink  lines,  indicating  the  vessels  along  the  posterior 
border  of  the  manubrium  ;  while  congestions  and  inflammations 
will  give  more  or  less  red  colour  to  the  whole  membrane,  pus, 
mucus,  or  other  secretions,  and  thickening  of  its  middle  or  internal 
layer  will  alter  or  intensify  the  colour-tone  of  the  membrane ; 
while  a  similar  condition  of  the  dermoid  epithelial  covering,  or 
deposits  thereon,  will  diminish  its  lustre.  At  the  point  where  the 
extremity  of  the  handle  of  the  malleus  is  in  apposition  with  the 
membrane  there  is  a  distinct  yellow  spot.  The  position  and  form 
of  this  spot  is  changed  by  alteration  in  the  position  of  the  malleus. 
Normally,  it  is  situated  at  about  the  centre  ot  the  membrane ; 
hence  the  term  tiinbo  (boss  or  navel).    Its  colour  is  affected  by 


Fig.  CCXXVII.— Normal  Membrana  Tympani,  Double  the  Natural  Size 

{afier  Politzer). 

A.  Handle  of  Malleus,  b.  Tip  of  Manubrium — Umbo.  c.  Short  Process  of  Malleus. 
D.  Posterior  Fold.  E.  Cone  or  Pyramid  of  Light.  F.  Membrana  Flaccida.  G.  Long 
Process  of  Incus. 

opacities  of  the  membranes ;  while  its  mobility  on  inflation  or 
exhaustion  is  impaired  if  there  be  anchylosis  or  adhesions.  The 
membrane  is  variably  transparent  in  different  subjects.  Besides 
the  maUeus,  one  can  sometimes  see  the  promontory  and  long 
shank  of  the  incus,  and  even  the  posterior  shank  of  the  stapes 
(Politzer),  pressing  as  it  were  against  the  window,  and  making 
at  these  points  a  distinct  clouding — very  different,  however,  from 
that  of  a  pathological  opacity. 

Form  is  nearly  circular,  the  membrane  being  rather  longer  in 
its  vertical  diameter,  which  is  something  like  two-fifths  of  an  inch 
in  length.  Many  practitioners  speak  only  of  the  anterior  or 
smaller  half,  c  e,  and  the  posterior  larger,  D  E,  the  portion 
between  d  and  c  comprising  the  membrana  flaccida  of  Shrapnell. 
For  general  purposes,  however,  the  membrane  may  more  conve- 
niently be  divided  into  four  segments,  the  boundaries  being 
formed  by  imaginary  lines  crossing  at  the  centre  in  the  direction 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  659 


of  the  handle  of  the  malleus  and  of  the  centre  of  the  cone  of  light. 
This  is  shown  in  the  small  schematic  diagrams  on  p.  663. 
The  shape  may  be  altered  by  variations  of  the  circumference  of 
the  bony  ring  to  which  the  membrane  is  attached,  and  apparently 
by  any  new  growth  in  the  meatus. 

Inclination. — The  membrana  tympani  in  its  normal  condition  is 
inchned  at  an  angle  of  45°  in  its  vertical  plane,  and  in  its  hori- 
zontal plane  is  inclined  10°  towards  the  right  on  the  right  side, 
and  10°  towards  the  left  on  the  left  side.  It  is  more  important  to 
note  that  the  antero-inferior  portion  of  the  membrane  is  further 
removed  from  the  external  opening  of  the  auditory  canal  than  the 
posterior-superior  part.  These  inclinations  must  be  considered 
when  estimating  the  size  of  the  membrane,  and  also  the  extent  of 
perforations,  opaque  spots,  etc. 

Curvature. — The  membrane  is  generally  described  as  funnel- 
shaped,  the  concavity  being  presented  to  the  eye  of  the  observer, 
and  the  apex  of  the  funnel  {umbo)  corresponding  to  the  end  of  the 
manubrium,  at  w^hich  point  the  membrane  is  drawn  distinctly 
inwards.  In  point  of  fact,  the  shape  is  that  of  a  funnel,  the  inner 
walls  of  which  are  slightly  convex.  The  concavity  is  increased 
by  anything  which  causes  undue  traction  on  the  manubrium  ; 
while  it  is  diminished  or  rendered  convex  on  inflation  of  the 
tympanum,  or  by  retained  purulent  or  other  secretions  in  that 
cavity. 

The  position  of  the  cone  of  light  is  represented  in  the  diagram. 
It  is  due  (i)  to  the  lustre ;  (2)  the  inclination  ;  and  (3)  to  the 
funnel  shape  of  the  membrane,  which  last  accounts  for  its 
pyramidal  form.  Anything,  then,  that  affects  lustre,  inclination, 
or  concavity  of  the  membrane  will  alter  the  brilliancy,  the  position, 
or  the  shape  of  this  light  spot.  It  may  also  be  stated  that  the 
more  concave  the  membrane,  the  smaller  the  pyramid  of  light ; 
and  the  more  convex,  the  larger  it  is.  This  may  be  demonstrated 
by  observing  it  under  inflation  or  exhaustion  of  the  cavity  of  the 
tympanum :  when  in  the  former  act  it  will  be  increased  in  size, 
while  by  the  latter  it  will  be  diminished. 

Surface  and  entirety  must  be  carefully  examined  in  all  cases, 
especially  whenever  there  is  any  discharge  from  the  ears  ;  in 
which  case,  after  gentle  syringing,  it  will  be  possible  to  determine 
whether  an  otorrhoea  is  external  to  the  membrane,  or  whether  it 
proceeds  from  the  tympanic  cavity.  In  this  last  event  there  will, 
of  course,  be  perforation,  and  there  may  be  also  granulations  or 
polypi.  Not  unfrequently  opaque  white  deposits,  often  of  cal- 
careous nature,  or,  it  may  be,  due  to  cicatrices,  will  be  observed 


66o  DISEASES  OF  THE  THROAT  AND  NOSE, 


on  the  surface  or  in  the  substance.  Inflammation  of  either  coat 
of  the  membrane,  and  many  affections  of  the  external  meatus,  will 
induce  changes  in  surface  smoothness  and  texture. 

Altered  mobility,  or  tension  and  adhesions  of  the  drumhead,  dis- 
covered by  observing  the  membrane  through  the  speculum  during 
the  act  of  inflation,  or  on  exhaustion  by  means  of  Siegle's  pneu- 
matic speculum,  are  all  occasionally  to  be  observed  as  results  of 
various  pathological  processes,  and  require  to  be  noted  by  the 
observer  as  indicating  anchylosis  of  the  ossicles,  undue  pressure, 
insufficient  muscular  accommodation,  or  the  products  of  inflam- 
mation. 

VII.  Knowledge  of  the  physical  condition  of  the  Tympanic 
Cavity  is  regulated  chiefly  by  the  appearance  of  the  membrane 
and  the  condition  of  the  Eustachian  tube,  supplementing  what  we 
may  have  gathered  by  tests  with  watch,  tuning-fork,  etc.,  and 
from  various  functional  symptoms.  It  is  above  all  important  to 
remember,  in  all  cases  of  inflammation  of  a  suppurative  character, 
the  very  delicate  and  intimate  relation  of  this  cavity  with  the 
membranes  of  the  brain,  and  with  the  lateral  sinus,  the  jugular 
fossa,  the  carotid  artery,  and  the  mastoid  cells. 

VIII.  The  Mastoid  Process  of  the  temporal  bone  is  often 
affected  by  periosteal  inflammation  and  by  suppuration  of  its 
cavity  as  an  extension  of  a  similar  condition  from  the  tympanum. 
In  all  inflammatory  diseases  of  the  tympanic  cavity,  the  mastoid 
should  be  carefully  examined  for  tenderness,  pain,  and  other 
inflammatory  signs.  In  such  a  case  treatment  by  leeching  will 
often  aid  diagnosis;  for  not  unfrequently,  even  when  signs  of 
actual  suppuration  are  absent,  leeching  or  incisions  down  to  or 
into  the  bone  are  attended  with  signal  benefit.  I  may  here 
mention  that  I  have  rarely  found  so-called  counter-irritation  by 
blistering  this  region  of  the  least  service  in  any  form  of  ear- 
disease. 

IX.  The  Eustachian  Tube  will  be  judged  to  be  pervious  by 
observation  with  the  auscultation-tube,  on  the  performance  of  the 
Valsalvan  act  of  inflation,  or  by  use  of  the  Politzer  bag,  the  latter 
with  or  without  assistance  of  the  catheter.  The  sounds  indicated 
in  the  case-form  will  show,  first,  by  the  force  of  the  *  thud,* 
whether  the  tube  is  open,  contracted,  or  impervious ;  and, 
secondly,  whether  the  tympanic  secretion  is  normal  (moist  sound), 
excessive  and  fluid  (bubbling),  deficient  (dry),  or  excessive  and 
inspissated  (crackling).  When  the  membrane  is  perforated,  the 
air  will  be  heard  to  rush  out  as  from  a  whistle  or  reed,  even 
without  aid  of  diagnostic  tube.    It  should  be  a  rule  never  to  pass 


AURAL  MALADIES  AND  NASO-FHARYNGEAL  DISEASE.  66i 


a  catheter  for  the  sake  of  diagnosis  until  failure  of  attenipted  in- 
flation by  the  Valsalvan  act  or  Politzer  bag  has  demonstrated  that 
the  tube  is  impervious  to  air  so  propelled. 

X.  New  Growths  will  often  require  careful  seeking,  especially 
granulations  within  the  tympanum  and  on  its  roof. 

XI.  Eye  Affections  are  to  be  noted  (and  treated)  in  all  cases 
of  syphilitic  affections,  especially  of  a  congenital  or  hereditary 
character ;  and  the  observer  should  also  seek  commemorative 
evidences  of  struma,  gout,  etc.,  in  teeth,  glands,  and  joints, 

[It  would  be  out  of  place  to  have  given  more  than  a  mere  outline  of  the  method  of 
examination  recommended.  Those  who  feel  stimulated  thereby  to  seek  further,  will  find 
admirable  directions  for  detailed  diagnosis  in  Toynbee's  classical  work  (Churchill),  in 
Keene's  concise  and  very  practical  '  Manual  of  Aural  Surgery  '  (Bogue),  and  in  Roosa's 
*  Practical  Treatise  on  Diseases  of  the  Ear '  (Wood  and  Co.).  Still  more  elaborate  explana- 
tion of  the  physiological  and  pathological  indications  afforded  by  tests  and  observations 
is  to  be  found  in  Burnett  on  '  The  Ear '  (Churchill).  This  author  also  describes  with  great 
detail  the  varying  appearances  of  the  tympanic  membrane,  for  information  concerning 
which  Politzer  (translated  by  Matthewson  and  Newton)  may  likewise  be  consulted,  as  also 
the  larger  work  by  the  same  author,  translated  by  Cassells  (Bailliere).  An  accurate  repre- 
sentation of  all  parts  of  the  auditory  apparatus,  with  much  interesting  information,  is  to 
be  found  in  W^itkowski's  *  Movable  Atlas  of  the  Ear,'  translated  by  the  author  (Bailliere).] 

Appended  is  the  form  which  I  have  prepared  for  the  taking  of 
an  aural  case,  in  accordance  with  the  foregoing  directions.  Books 
of  them  are  sold  by  Bailliere  and  Co.  A  shorter  form  for  use  in 
our  out-patient  department  is  printed  at  page  667  >  but  our 
clinical  assistants  are  always  urged  to  observe  the  same  patient 
and  systematic  method  of  investigation  that  the  more  detailed 
form  necessitates. 


662 


DISEASES  OF  THE  THROAT  AND  NOSE. 


AURAL  CASE. 

History. — Giving,  in  order,  Patient's  account  of  previous  aural  trouble;  symptoms  of 
present  attack  in  order  of  sequence,  as  observed  by  patient,  with  supposed  cause  of  the 
same,  and  especially  causes  believed  to  aggravate  the  symptoms,  such  as  damp,  high 
winds,  fatigue,  anxiety,  etc.,  or  to  improve  them,  such  as  dry  climates,  rest,  food,  sur- 
rounding noises,  etc.  Endeavour  to  ascertain  exact  date  of  first  perceived  loss  of  hearing 
power,  and  also  date  of  any  exanthem  from  which  patient  m,ay  have  suffered. 

Family  History. — Evidence  of  Hereditary  Influence,  i.e.,  of  other  deaf  members  of  ihe 
same  family,  and  of  Syphilis,  Struma,  Gout,  etc. 

General  Health— Temperament,  etc. 

Circulation— Pulse,  etc. 

Respirations— Number  of,  etc. 

Temperature. 

Digestion. 

Excretion. 

Nutrition— Weight 

A.  Functional  and  Subjective  Symptoms  : 

I.  HEARING  POWER. 

Conversation — Ordinary,  loud,  or  shouting. 

Note  whether  patient  watches  lip-movement  of  speaker  and  hears  equsUy 
well  with  eyes  closed  as  with  them  open. 

Whisper— Low,  ordinary,  loud. 

Watch— Right. 
Left. 

Tuning-fork— Note  {a)  Intensity,  {b)  Duration  of  Vibrations  as  heard. 

a.  External  Meatus— Right. 

Left. 

b.  Vertex— Mastoid,  Teeth,  etc. 

Note  whether  heard  louder  on  the  deafer  side  of  the  head. 
Right. 
Left. 

c.  Vertex,  etc. — External  meatus  being  closed. 

Note  the  same  facU 
Right. 
Left. 

II.  DISCHARGE. — Duration— Whether  constant  or  intermittent.  Nature— 
"Whether  serous,  purulent,  or  sanguineous  ;  whether  of  offensive  smell. 

Right. 
Left. 


III.  PAIN— Character  and  Situation. 
Right. 
Left. 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE. 


663 


IV.  TINNITUS. — Nature  of  Sounds  as  described  by  Patient  ;  whether  constant  or 
intermittent.  Class  of  Sound  ;  whether  (a)  Humming  or  Buzzing,  {d)  Crackling  or 
Rustling,  (c)  Tidal,  to  and  fro,  {d)  Bubbling,  Gurgling,  or  Singing,  {e)  Constant 
Rushing,  (/)  Pulsating,  (^)  Anomalous. 

Right. 
Left. 

V.  VERTIGO. — Ascertain  date  of  origin,  frequency,  and  character,  whether  reeh'ng 
to  and  fro,  staggering  forwards,  or  actually  falling,  etc.  Whether  accompanied  by 
vomiting,  loss  of  consciousness,  etc. 

VI.  NASAL  RESPIRATION.— Whether  free  or  obstructed  unilaterally  or  bila- 
terally.    Character  of  odour  of  expired  breath. 

VII.  DEGLUTITION,  etc.— How  affected.  (For  special  Throat  symptoms  see 
Throat  Case  Paper.) 

B.  Physical  and  Objective  Signs: 


> 
< 
U 

< 
U 

u 


Tongue. 

Walls. 

Velum. 

Fauces. 

Uvula. 

Tonsils. 


See  Chap. 
IIL,  p. 
53. 


II.  PHARYNX. 

By  Rhinoscope. 
(Chapter  V.) 


By  Anterior  Exam. 


we 

< 

^  Oh  vBy  Palpation. 

IV.  AURICLE. 

Right. 
Left. 


V.  MEATUS. 


Right. 
Left. 


VI. 


MEMBRANA 
TYMPANI. 


Right. 
Left. 


Colour,  Form,  etc. 


Surface,  Entirety, 
Secretion,  etc. 


Position,  Mobility, 
etc. 


Nere  are  inserted 
outline  diagrams 
of  I'auces,  Pos- 
terior A'ares,  and 
sections  o/Nares, 
as  in  Throat 
Forms  {p.  88). 


Colour, 
Lustre, 
Trans- 
parency. 


Form  and 
Inclination. 


Curvature, 
Cone  of 
Light. 


Surface  and 
Entirety, 
Granula- 
tions, etc. 


Mobility, 
Tension,  and 
Adhesions. 


Fig.  CCXXVIII.— Outline  of  Membrana  Tympani,  with  Imaginary  Sectional 

Lines  (Normal  Size). 


664 


DISEASES  OF  THE  THROAT  AND  NOSE, 


VII. 


VIII. 


AURAL  CASE  FAFER—Continued. 

TYMPANIC 
CAVITY. 

Right. 
Left. 

MASTOID 
PROCESS. 


Right. 
Left. 

IX.  EUSTACHIAN  TUBE— Whether  pervious;  to  Valsalvan  inflation;  to 
Politzer  inflation  ;  to  Catheter. 

Character  of  Impulse  on  Inflation  as  heard  by  Diagnostic  or  Auscultation  Tube  ;  whether 
full,  diminished,  or  suppressed  ;  moist  or  bubbling,  dry  or  crackling. 
Right. 
Left. 

X.  NEW  GROWTHS— Either  External  or  Internal,  influencing  the  hearing. 

XL  EYE  AFFECTIONS. 

Right.  ' 
Left. 


CHAPTER  XXVIL 


AUEAL  MALADIES  ASSOCIATED  WITH  NASO  PHARYNGEAL 

DISEASE. 

PART  II.— GENERAL  ETIOLOGY  AND  THERAPEUTICS. 

In  a  previous  portion  of  this  volume  (p.  95)  I  have  alluded  to  the 
absolute  necessity  of  those  who  aspire  to  successfully  treat  throat 
affections,  to  be  ati  fait  With,  the  principles  and  practice  of  aural 
surgery,  as  w^ell  as  for  the  aurist  to  extend  his  investigations 
beyond  the  region  of  the  ear  proper  to  the  passages  of  the  nose 
and  throat.  Such  remarks  now^adays  savour  of  truism,  but  it  is 
only  in  comparatively  recent  times  that  writers  on  throat  and  ear 
diseases  have  sufficiently  insisted  on  this  fact.  Even  now  the  de- 
partments of  the  ear  and  throat  are  kept  distinct  in  those  of  our 
general  hospitals  where  such  special  departments  exist,  and  they 
are  officered  by  different  practitioners  in  each  case.  Ten  years 
ago  aural  symptoms  were  indeed  almost  ignored  at  throat  hos- 
pitals; and  until  quite  recently  patients  with  symptoms  of  ear 
trouble  were  in  the  charge  of  a  member  of  the  staff  told  off 
specially  for  that  duty,  who  attended  to  them  but  once  a  week : 
this  must  have  amounted  in  many  instances  to  a  mere  apology 
for  treatment.  The  statistics  of  the  Central  Throat  and  Ear 
Hospital  afford  incontestable  proof  that  such  an  artificial  divorce 
of  subjects  which  are  by  nature  so  closely  wedded,  is  calculated  to 
lead  to  incompleteness  both  of  diagnosis  and  treatment. 

In  the  thirteen  years  just  completed  since  our  hospital  was 
founded  (March,  1874),  over  59,000  new  cases  {i.e.f  absolutely 
different  individuals)  have  been  treated.  In  the  year  1886  the 
number  of  out-patients  was  4,946.  They  were  classified  by  the 
Secretary  on  the  patient's  first  application  as  follows : 

1731  were  suffering  from  diseases  of  the  pharynx  and  larynr.. 


115  ,,  tongue  and  mouih. 

254  nasal  passages. 

1980  ear  connected  with  throat  affections. 

C78  ,,  of  the  ear  alone. 

18S  „  external  throat  and  neck. 


666 


DISEASES  GF  THE  THROAT  AND  NOSE. 


The  above  secretarial  figures  represent  the  statements  of  the 
patients  themselves  of  the  complaints  for  which  they  applied  to  the 
hospital,  and  they  necessarily  underwent  considerable  correction 
at  the  hands  of  the  Surgical  Registrar ;  for  whilst  there  are  many 
throat  affections  which  cause  aural  symptoms,  there  are  also 
many  cases  of  deafness  due  to  naso-pharyngeal  disease,  of  which 
the  patient  is  either  unaware,  or  which  he  himself  does  not 
connect  with  his  defective  hearing.  Analyzing  the  above  figures 
in .  the  light  of  these  remarks,  with  the  aid  of  the  Surgical 
Registrar's  report,  it  was  found  that  of  the  throat  affections  often 
associated  with  aural  disease,  and  of  the  aural  cases  mostly  con- 
nected with  diseases  of  the  throat,  the  numbers  required  the 
following  modifications : 

Of  the  Pharynx  : 

Subacute  inflammation  and  congestion          ....  265 

Follicular  and  granular  inflammation            -          -          •          -  57 

Acute  tonsillitis         -          -          -          -          -          -          -  122 

Hypertrophic  inflammation  of  the  tonsils       ....  350 

Chronic   inflammation  without  enlargement  (lacunar  or  so-called 

follicular  disease)            ......  85 

Adenoid  growths  (hypertrophy  of  the  pharyngeal  tonsil)       -          -  39 

91S 

Of  the  Middle  Ear : 

Purulent  inflammation  (acute  and  chronic),  including  aural  polypi 

(8i),  and  mastoid  caries  (8)        -  -  -  -  -  815 

Non-purulent  inflammation  (subacute  and  chronic)  ...  833 
Catarrhal  obstruction  of  the  Eustachian  tube  -  •  -  124 

1772 

Of  the  Nasal  Passages  : 

Subacute  and  chronic  inflammation  (including  hypertrophic,  atro- 
phic and  post-nasal  catarrh)        -  -  -  -  -  211 
Nasal  polypi  -.-.-.--43 

254 

Total  .....  2944 

Although  many  cases  have  been  eliminated  from  the  list  of  the 
pharyngeal  disorders  in  which  defective  hearing  is  only  occa- 
sionally a  symptom,  as  in  syphilitic  ulceration  of  the  pharynx,  it 
is  seen  that  on  our  list  for  one  year  there  is  an  excess  of  nearly 
1,000  cases  over  the  number  estimated  simply  by  the  patients 
themselves,  in  which  ear  symptoms  might  be  looked  for. 

I  do  not  wish  to  imply  that  deafness  is  present  in  all  or  even  in 
a  majority  of  cases  of  pharyngitis,  tonsillitis,  and  naso-pharyngeal 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  ^67 


diseases ;  but  I  do  hold  that  the  hearing  power  should  always  be 
accurately  tested  in  such  cases.  On  the  other  hand,  in  many 
instances  of  Eustachian  catarrh  and  of  enlarged  tonsils,  there  is 
an  associated  existence  of  adenoid  growths.  And  again,  by  far 
the  commonest  excitant  of  middle-ear  maladies  is  disease  of  the 
nasal  and  post-nasal  regions,  and  this  is  made  a  special  point  in 
the  case-forms  of  our  hospital,  a  reduced  facsimile  of  which  is 
subjoined. 

Registered  No  

CENTRAL  LONDON  THROAT  AND  EAR  HOSPITAL 

Name   Age   Occupatio7i  

Address   ;  

UNDER  THE  CARE  OF   


Throat  Disease., 
Duration  of  Illness 

Complains  of  

Supposed  Cause  

^-  (  Voice  , 

§  Cough  

I  Respn  

'o^  \Degln  

Smell  and  Tas/e  

Fain   

Naso-Pharynx  ..... 


Ear  Disease   

DiLration  of  Illness   

Complains  of  

Supposed  Cause  

cConvn.  R  Watch  R. 

L  ,  L. 

meatus 

T.F.-!  R  L. 

mastoid 

Discharge   Pain  

Tinnitus    Vertigo... 


[at . 
I  on 


Larynx 


Thorax 


General  State . 


Space  for  dia- 
gra77i  for  indi- 
cating tnorbid 
changes  (p.  88). 


Prescriptions. 


TREATMENT. 


Instrumental  and  Notes  of  Progn 


Date. 


Date. 


668 


DISEASES  OF  THE  THROAT  AND  NOSE, 


It  will  be  seen  that  whilst  each  case-paper  is  arranged  in  two 
separate  columns,  one  for  the  record  of  the  condition  of  the 
pharynx,  larynx,  and  the  lower  air-passages,  and  another  for  notes 
on  the  various  parts  of  the  ear,  there  is  also  a  space  common  to  both 
for  remarks  on  the  condition  of  the  naso-pharynx. 

It  is  only  by  daily  recognition  and  acknowledgment  of  this 
intimate  connection  between  these  three  regions — the  throat,  the 
nose,  and  the  ear — that  thorough  work  can  be  done  in  either. 
The  mysteries  of  the  larynx  may  be  confined  to  the  pure 
laryngologist,  as  may  those  of  the  chambers  of  the  internal  ear 
to  the  aurist ;  but  either  one  or  other  would  be  imperfectly 
explored  if  the  investigator  neglected  to  examine  the  avenues 
to,  and  the  surroundings  of,  these  inner  and  deeply-seated 
structures. 

The  diseases  of  the  pharynx  and  nasal  passages  capable  of 
causing  aural  symptoms  have,  in  a  measure,  been  considered  in 
their  appropriate  situations,  and  the  proportions  which  this  book 
has  already  assumed,  preclude  my  entering  at  any  length  into 
the  wide  subject  of  middle-ear  disease,  the  result  or  complication 
of  naso-pharyngeal  maladies.  Acting,  however,  on  an  expressed 
wish  of  many  former  pupils  and  friends,  I  have  summarized  in  the 
preceding  chapter  the  directions  I  am  in  the  habit  of  giving  for 
the  proper  investigation  of  a  case  with  aural  symptoms,  and  the 
form  on  which  our  hospital  notes  are  taken. 

I  shall  now  proceed  to  make  some  general  deductions  from  the 
information  thus  afforded,  which  may  aid  treatment. 

It  may  be  generally  stated  that  in  almost  every  case  of  deafness 
connected  with  the  throat,  there  is  an  imperfect  performance  of 
the  functions  of  the  Eustachian  tube  in  relation  to  the  rest  of  the 
auditory  apparatus.  To  better  appreciate  the  importance  of  this 
fact,  a  few  words  are  required  to  explain  the  anatomical  con- 
struction and  physiological  duties  of  the  Eustachian  tube  ;  after 
which  I  shall  indicate  the  principal  diseased  conditions  which  may 
impair  its  efficiency. 

Reverting  to  our  anatomy  (p.  33),  it  will  be  remembered 
that  the  Eustachian  canal  passes  from  the  pharynx  to  the  middle 
ear  in  an  upward,  outward,  and  backward  direction.  The  inner 
two-thirds  of  the  tube  has  a  slit-like  lumen,  as  from  compression 
from  before  backwards,  and  somewhat  from  below  upwards ;  this 
lumen  is  greatest  at  the  trumpet-shaped  opening  into  the  pharynx, 
and  narrowest  at  (roughly)  the  junction  of  the  inner  two-thirds 
with  the  outer  third ;  from  this  point — the  isthmus — it  widens 
again  to  expand  into  the  tympanum.    The  wall  of  this  outer 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  669 


portion  consists  of  bone,  covered  by  a  very  thin  ciliated  mucous 
membrane,  the  ciHary  action  being  towards  the  pharyngeal  out- 
let. The  inner  and  longer  portion  of  the  canal  consists  of  a 
split  tube  of  cartilage;  the  deficiency  in  the  wall  below  and 
somewhat  in  front,  which  increases  as  the  pharynx  is  neared,  is 
filled  in  by  mucous  membrane  and  fibro-muscular  structures. 
The  trumpet-shaped  opening  into  the  pharynx  is  seen  on  section 
to  be  bounded  behind,  above,  and  partially  in  front  by  a  hook- 
shaped  scroll  of  cartilage ;  the  upper  and  posterior  portions 
being  fixed  to  the  base  of  the  skull,  and  the  anterior  hook  being 
slightly  movable.  Below  the  hook,  anteriorly  and  inferiorly,  the 
tube  is  completed  by  membrane.  It  is  only  at  the  faucial  orifice 
and  at  the  isthmus  that  this  membrano-cartilaginous  part  of  the 
tube  is  normally  patent ;  in  the  intermediate  area  the  mucous 
surfaces  are  in  contact,  so  that  the  practically  obliterated  lumen 
forms  an  S-shaped  slit.  This  arrangement  is  of  importance  in  regu- 
lating the  supply  of  air  to  the  tympanum,  for  ii.  is  a  potential  valve 
which  is  only  released  by  action  of  the  muscle  that  is  inserted 
into  the  membranous  wall,  and  into  the  hook-Hke  portion  of 
cartilage.  This  muscle,  which  is  commonly  called  the  tensor  palati, 
but,  as  Von  Troltsch  suggests,  might  more  properly  be  denomi- 
nated the  dilatator  tiihce,  has  little  or  no  action  on  the  soft  palate ; 
but  during  its  normal  contraction  in  swallowing,  it  acts  on  the 
membranous  portion  of  the  tube  and  on  the  hook-like  scroll,  widen- 
ing the  lumen  by  its  direct  action  on  the  former,  and  by  tending 
to  unroll  the  latter. 

Many  authors  ascribe  an  equally  important  action  to  the  levator 
palati ;  but  as  it  is  situated  almost  parallel  to  the  m.embranous 
wall,  its  only  action  is  to  force  the  floor  upwards  and  backwards. 
Acting  alone,  it  would  tend  to  compress  the  tube  and  obliterate  its 
lumen  by  its  contracting  belly  heaving  the  floor  up,  so  to  speak. 
This  consideration  led  Politzer  and  Cleland  to  deny  its  dilating 
function  altogether  ;  but,  for  my  part,  I  think  that,  acting  in  con- 
junction with  the  tensor  palati  {dilatator  tiihce),  the  upheaving  action 
of  the  levator  must  tend  to  an  increase  of  the  transverse  diameter 
of  the  passage.  It  is  doubtless,  however,  principally  a  palatal 
muscle. 

The  salpingo-pharyngeus  plays  no  very  important  part  in  the 
human  species.  It  is  only  exceptionally  present,  more  rarely  bi- 
lateral, and  its  representation  in  a  degraded  form  as  a  strip  of 
fascia  is  not  even  constant.  When  muscular,  it  would  contribute 
only  to  the  fixed  position  of  the  median  portion  of  the  cartilage. 
-  During  the  act  of  sv/allowing  the  Eustachian  tube  is  rendered 


670 


DISEASES  OF  THE  THROAT  AND  NOSE, 


patent  by  the  conjoined  action  of  these  before-mentioned  muscles, 
and  it  is  thus  that  intra-tympanic  pressure  is  regulated. 

Politzer  draws  attention  to  the  important  fact  that  *  the 
Eustachian  canal  in  the  child  differs  considerably,  as  regards 
length,  width,  and  direction,  from  the  adult.  Its  tympanic  orifice 
is  comparatively  large,  and  lies  somewhat  lower  ;  on  the  other 
hand,  the  pharyngeal  orifice  is  indicated  only  by  a  slight  de- 
pression or  fissure,  and  the  posterior  (usually  prominent)  position 
of  the  tube  forms  a  hardly  noticeable  projection  in  the  wall  of  the 
pharynx.  The  tube  in  the  child  is  also  shorter  and  wider,  a  con- 
dition which  is  of  practical  importance,  in  so  far  as  obstacles  in  it 
caused  by  the  products  of  disease  can  with  greater  facility  be 
removed  by  a  current  of  air.' 

For  perfect  hearing,  it  is  essential  that  there  should  be  free 
ventilation  of  the  tympanum  through  the  Eustachian  tube,  and 
that  the  mouth  of  this  canal  should  be  freely  opened  by  muscular 
action  at  certain  times.  All  conditions  which  tend  to  narrow  the 
lumen  by  swelling  of  the  mucous  membrane,  or  which  hamper  the 
action  of  the  muscles,  will  prevent  the  equilibration  of  intra- 
tympanic  pressure,  and  cause  retention  of  secretion,  and  thus 
inevitably  lead  to  middle-ear  disease  and  its  sequelae. 

Non-specific  catarrhal  affections  of  the  neighbouring  mucous 
membrane,  by  extension,  often  bring  about  the  same  condition  in 
the  tubes  in  continuity. 

The  chief  naso-pharyngeal  maladies  of  this  nature  arc  : 

I.  Hypertrophic  rhinitis,  causing  swelling  of  the  tube,  with 
perverted  and  thick  secretion. 
II.  Atrophic  rhinitis,  in  which  there  is  destruction  of  cilia 
by  the  backward  extension  of  inflammation  from  the 
nose  and  its  accessory  sinuses,  leading  to  a  similar  con- 
dition of  the  Eustachian  orifice,  and  eventually  (also  by 
extension)  to  dry  catarrh  of  the  tube  and  tympanum. 
III.  Growths  in  the  naso-pharynx  inducing  Eustachian  ob- 
struction, either  by  contact  with  the  orifice,  or  by  the 
induced  post-nasal  catarrh  of  the  neighbouring  mucous 
membrane.  Under  this  category  come  adenoid  groiL'tlis, 
naso-pharyngeal  ttunotivs,  polypoid  hypertrophy  of  the  pos- 
terior extremities  of  the  turbinated  bodies,  and  true  nasal 
polypi,  which  may  project  into  the  naso-pharyngeal  space. 

In  addition  to  the  foregoing,  which  either  directly  block  the 
Eustachian  orifice  by  mechanical  obstruction,  or  indirectly  by 
inducing  an  extension  of  the  catarrhal  process,  there  are  other 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  671 


conditions  which,  if  of  long  standing,  lead  to  Eustachian  obstruc- 
tion by  impeding  the  action  of  the  muscles  which  open  the  mouth 
of  the  tube.    Under  this  heading  are  included  : 

IV.  Enlargements  of  the  tonsils,  whether  benign  or  malig- 
nant. Tonsillar  hypertrophy  never  directly  obstructs  the 
Eustachian  orifice,  but  by  its  frequent  upward  exten- 
sion the  palate  is  pushed  up,  and  the  action  of  the 
muscles  thereby  markedly  impeded.  It  must  also  be 
remembered  that  there  is  nearly  always  associated 
catarrhal  naso-pharyngitis ;  and  in  the  young,  up  to  the 
ages  of  15  or  20,  there  will  frequently  be  concomitant 
adenoid  hypertrophy  of  the  pharyngeal  tonsil,  and  occa- 
sionally catarrh  of  Luschka's  pouch  {Tornwaldfs  disease), 
V.  Enlargements  of  the  palate,  whether  of  the  nature  of 
a  gumma,  hcematoma,  or  abscess  (suppurative  peritonsillitis), 
occasionally  give  rise  to  Eustachian  and  middle-ear 
disease. 

VI.  Paralysis  of  the  palate,  diphtheritic  or  bulbar,  is  sometimes 
attended  by  Eustachian  blocking.  Under  this  head  may 
be  also  included  the  defective  muscular  arrangements  of 
cleft  palate,  congenital  or  acquired. 

Various  specific  diseases  which  affect  the  throat  may  extend 
to  the  tube  and  tympanum. 
VIL  Under  this  heading  are  included  scarlet  fever,  measles,  small- 
pox, diphtheria,  and  less  frequently,  in  an  acute  form, 
pneumonia,  glanders, _  insanitary  sore  throat,  and  phlegmonous 
erysipelas. 

The  effects  of  syphilitic  extension  along  the  Eustachian  tube  is 
seldom  of  an  acute  nature  or  suppurative.  Tubercle  acts  also 
subacutely  and  slowly ;  when  manifested  it  often  leads  to  disin- 
tegration of  the  membrane,  and  is  then  the  cause  of  a  purulent 
discharge. 

Finally,  in  this  connection  may  be  mentioned  middle-ear 
trouble,  due  to  the  forcing  of  mucus  or  of  ingesta  i-nto  a  very  patent 
tube.  This  exceptionally  occurs  in  whooping-cough,  persistent  vomit- 
ing, and  unskilful  or  excessive  catheterization.  Temporary  in- 
convenience is  sometimes  caused  by  coughing,  sneezing,  and  a 
trumpeting  mode  of  blowing  the  nose.  It  is  a  question  whether 
in  pertussis,  which  is  very  generally  considered  a  parasitic  disease, 
and  of  which  otorrhoea  is  a  frequent  sequel,  morbific  germs  may 
not  enter  the  middle  ear  by  the  Eustachian  tube  during  a 
paroxysm  of  coughing. 


672  DISEASES  OF  THE  THROAT  AND  NOSE. 


The  Eustachian  orifices  have  occasionally  been  injured  by 
traumatism,  caustic  poisons,  and  scalding  fluids.  These  rare  accidents 
are  more  liable  to  happen  in  connection  with  cleft  palate. 

The  conditions,  then,  capable  of  causing  so-called  throat  deaf- 
ness are  many  and  varied,  and  so,  it  may  be  added,  are  the 
results. 

The  first  stage,  as  before  mentioned,  is  usually  hypertrophic 
catarrh  and  blocking  of  the  tube ;  this  may  lead  to  either 
mucoid,  serous,  or  suppurative  catarrh  of  the  tympanum.  The 
latter  may  go  on  to  acute  inflammation,  perforation,  chronic 
otorrhoea,  granulations,  polypi,  exostoses,  necroses,  etc.  ;  or  to 
mastoid  abscess,  labyrinthine  disease,  with  associated  tinnitus, 
vertigo,  and  even  intra-cranial  suppuration. 

Treatment  of  chronic  non-suppurative  catarrh  consists,  in 
the  first  place,  in  removing  the  diseased  state  which  originally 
brought  about  the  Eustachian  malady.  The  appropriate  treat- 
ment of  these  exciting  nasal  and  naso-pharyngeal  diseases  has 
been  discussed  under  the  sections  dealing  with  these  conditions. 
The  ear  trouble  itself  requires  early  and  active  attention. 

The  chief  indications  in  non-suppurative  catarrh,  in  addition  to 
removal  of  the  naso-pharyngeal  malady,  are  : 

I.  To  open  up  the  Eustachian  communication  between  the 
tympanum  and  the  pharynx,  that  the  scretions  may  escape,  and 
that  equilibrium  between  intra-tympanic  pressure  and  that  of  the 
external  air  may  be  restored. 

II.  To  treat  the  diseased  lining  membrane  of  the  tube  and 
tympanum,  and  bring  it  back  as  near  as  is  possible  to  the  normal. 

III.  By  general  dietetic  and  hygienic  measures  to  diminish 
any  diathetic  predisponent  to  catarrh. 

As  regards  the  first  indication,  namely,  mechanically  opening 
up  the  Eustachian  tube  by  means  of  a  blast  of  air,  the  simplest 
and  in  some  cases  an  efficient  method  is  that  of  Valsalva,  In  this 
procedure  the  middle  ear  is  inflated  by  making  a  forced  exspiration 
with  the  lips  closed  and  the  nostrils  held.  It  is  only  adapted  to 
those  cases  where  the  Eustachian  resistance  is  inconsiderable.  A 
sense  of  fulness  with  (sometimes)  slight  singing  in  the  ear  indicates 
a  successful  effort.  Not  more  than  one  thorough  inflation  should 
be  made  on  a  single  occasion.  The  converse  of  this  mode  of 
inflation,  namely,  exhaustion  of  the  tympanum  by  swallowing  the 
saliva  several  times,  the  lips  and  nares  being  closed,  is  occasionally 
useful  in  active  catarrh,  and  also  in  connection  with  painful  sensa- 
tions due  to  hyper-distension  after  inflation  by  air,  or  the  accidental 
introduction  of  fluids  as  a  result  of  nasal  syringing.    The  act  of 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  673 


swallowing  tends  to  open  the  orifice  of  the  tube,  and  if  the  month 
and  nostrils  are  closed,  a  suction  action  is  exerted  on  the  tym- 
panum and  on  any  retained  secretion. 

If  the  tympanic  membrane  is  non-adherent,  these  induced  varia- 
tions of  intra-tympanic  pressure  are  evidenced  by  a  change  of 
curvature,  which,  in  cases  of  perforation,  can  be  demonstrated 
by  fixing  a  manometer  to  the  meatus. 

Politzer's  method,  which  is  more  efficient  and  thorough,  depend?? 
on  the  fact  that  the  act  of  swallowing — say  a  small  quantity  of 
water — helps  to  render  the  Eustachian  tube  patent  by  muscular 
action,  while  the  necessary  apposition  of  the  soft  palate  to  the 
posterior  wall  of  the  pharynx  shuts  off  the  nasal  cavity  behind. 
If  a  forcible  blast  of  air  be  injected  from  a  bag  into  one 
nostril,  the  other  being  closed,  and  simultaneously  with  the  act 
of  swallowing,  intra-nasal  pressure  will  be  greatly  increased ;  this 
pressure  will  usually  be  sufficient  to  overcome  the  Eustachian 
resistance,  and  air  will  thus  pass  into  the  tympanum.    In  children, 


Fig.  CCXXIX.— Author's  Form  of  Politzer  Bag. 


on  account  of  the  peculiarities  already  alluded  to,  the  act  of 
swallowing  is  unnecessary  :  crying  ;  saying  the  words  '  ah  '  hie,' 
*  haec,'  *  hoc ;'  or  indeed  almost  any  non-7iasal  articulate  sound, 
will  be  sufficient  to  approximate  the  palate  to  the  posterior 
pharyngeal  wall.    The  simplest  and  cheapest  form  of  Politzer-bag 


Fig.  CCXXX.— Keene's  Form  of  Politzer  Bag, 


is  that  depicted  in  Fig.  CCXXIX.  The  nozzle  is  of  soft  rubber, 
with  an  inner  firmer  piece  to  provide  against  closure  of  the 
aperture  when  the  nostrils  are  compressed. 

Another  useful  form  is  that  known  as  Keene's  (Fig.  CCXXX.), 
the  nasal  piece  of  which,  on  removal  of  the  soft  nozzle,  is  made 

43 


674 


DISEASES  OF  THE  THROAT  AND  NOSE, 


SO  as  to  fit  into  the  opening  of  a  catheter ;  it  has  also  a  box  into 
which  iodine,  chloroform,  or  other  drug,  sprinkled  on  wool,  can  be 
introduced,  and  thus  the  Eustachian  tube  can  be  medicated 
as  well  as  inflated  by  the  one  process.  The  first  variety  of  in- 
flating bag  is  preferable  for  the  patient's  self-use  ;  the  second  for 
that  of  the  surgeon. 

If  inflation  is  unsuccessful  by  Politzer's  method,  recourse  must 
be  had  to  the  Eustachian  catheter ;  when  this  is  in  position  in  the 
Eustachian  orifice,  an  air-bag  is  connected  directly 
or  indirectly  by  rubber  tubing  with  the  wide  end  ;  a 
blast  of  air  is  easily  forced  into,  the  tube  in  most  in- 
stances. This  method  is  often  described  as  painless, 
but  it  is,  to  say  the  least,  decidedly  and  universally 
unpleasant.  Frequent  catheterization  may  in  any 
case  do  harm  by  irritation  of  the  Eustachian  orifice, 
and  in  the  hands  of  unskilful  persons  actual  injury 
may  result.  In  other  circumstances  this  simple  irri- 
tation has  the  effect  of  stimulating  a  paretic  dilatator 
tiihcd  to  healthy  contraction.  After  the  passage  has 
been  opened  up  in  this  way,  it  is  usually  possible 
to  keep  it  patent  by  systematic  Politzerization,  a 
treatment  which  the  patient  may  be  taught  to  practise 
for  himself.  In  my  own  experience  catheterization 
is  rarely  necessary  or  desirable  more  than  once  a 
week  or  fortnight,  even  in  bad  cases. 

Ward  Cousins  has  recently  described  in  the  British 
Medical  Journal  an  instrument  which  depends  on  a 
combination  of  the  principles  and  methods  of  Politzer 
and  Valsalva.  It  consists  of  two  communicating 
nozzles  for  fitting  into,  and  accurately  closing,  the 
anterior  nares ;  and  in  connection  with  this  nose 
arrangement,  two  bags,  one  with  an  inflating  and 
the  other  an  exhausting  action.  By  means  of  this 
apparatus,  if  the  patient  makes  a  forcible  effort  of 
exspiration  with  the  lips  closed,  as  in  Valsalva's 
method,  the  tympanic  cavity  can  be  alternately  in- 
flated and  evacuated.     This  plan  gets  rid  of  the 

Fig.  CCXXXI.  occasional  deposition  of  mucus  in  the  middle  ear 
Ward  Cousins'      ...  ,  ,         ,  ,  i     i  i     i  •  i  • 

Instrument  which  may  happen  by  otner  methods,  and  which  is 

FOR  Tinnitus.  ^  ygj-y  painful  and  harmful  accident.  This  alter- 
nate inflation  and  evacuation  has  been  used  by  the  inventor  with 
success  in  cases  of  tinnitus  connected  with  middle-ear  catarrh. 
Our   experience  with  this  somewhat  complicated  method  in 


AURAL  MALADIES  AND  NASO-PHARYNGEAL  DISEASE.  675 

hospital  practice  has  been  as  yet  too  limited  to  justify  us  speaking 
more  than  encouragingly  of  it. 

As  regards  the  application  of  fluids  to  the  lining  membrane  of 
the  Eustachian  tube  and  tympanum  by  means  of  injection  through 
the  catheter  or  otherwise,  I  have  long  held  objections  to  the 
practice  as  one  which  is  painful,  dangerous,  and  in  most  cases 
useless ;  and  I  find  it  difficult  to  too  emphatically  condemn  it  in 
cases  of  non-suppurative  catarrh,  uncomplicated  by  perforation  of 
the  membrana  tympani. 

Vapours. — Inhalations  of  the  vapour  of  chloride  of  ammonium 
by  means  of  the  Burroughs  or  other  inhaler,  are  of  great  use 
in  those  cases  in  which  steam  inhalations  are  inadmissible 
from  liability  to  increase  the  catarrhal  disposition.  They  may 
be  employed  by  the  patient  performing  the  Valsalvan  act 
occasionally  during  ordinary  inhaling,  or  the  vapour  may  be 
passed  directly  to  the  tympanum  by  means  of  the  catheter  as 
first  advocated  by  Politzer.  It  is  in  such  cases  requisite  that 
the  ammonia  vapour  should  be  strictly  neutral.  In  our  practice 
this  is  provided  for  by  its  passing  through  a  slightly  acidulated 
water-chamber.  A  few  drops  of  litmus  solution  in  the  latter 
enables  the  surgeon  to  recognise  the  neutrality  or  otherwise  of 
the  vapour. 

Should  there  be  unabsorbed  mucus  in  the  tympanum  which  re- 
sists the  before-mentioned  methods,  or  which  cannot  be  dispelled 
by  the  passage  of  medicated  vapours,  a  small  perforation  may  be 
made  in  the  postero-inferior  quadrant,  and  a  current  of  air  passed, 
to  be  followed  in  some  instances  by  a  weak  solution  of  carbonate 
of  soda  of  not  more  than  ten  grains  to  the  ounce.  If  the  mucus 
is  inspissated  and  not  dissolved  by  this  means,  suction  is  to  be 
employed  through  the  perforation  by  means  of  a  Siegle's  speculum. 
This  instrument  I  have  had  connected  with  an  exhausting  air- 
bag,  which,  while  stronger  and  aesthetically  preferable  to  an  oral 
suction  tube,  is  not  the  dangerously  powerful  instrument  that  has 
recently  been  introduced  into  practice.  The  instrument  which  I 
advocate,  while  sufficiently  strong  to  break  down  adhesions  of 
retracted  membranes,  is  under  perfect  control  for  less  energetic 
exhaustive  efforts. 

It  is  necessary  to  repeat  that  combined  with  these  measures,  and 
as  a  rule  preceding  them,  the  greatest  attention  must  be  given 
to  the  condition  of  the  throat,  and  to  improvement  of  the 
pharyngeal  and  nasal  secretions  by  inhalations,  lozenges,  local 
applications,  and  by  the  posterior  nasal  douche  (Fig.  LXXIL, 
p.  121).    This   last   measure  is  immensely  preferable   to  the 


676 


DISEASES  OF  THE  THROAT  AND  NOSE. 


anterior,  for  the  reason  that  fluid  is  less  Kkely  to  enter  the 
Eustachian  tube  and  tympanum. 

Suppurative  Catarrh  of  the  middle  ear  is  usually  presented  to 
the  specialist  in  the  chronic  stage  with  perforation  of  the  tympanic 
membrane.  Acute  suppuration  may  occur  in  the  course  of  certain 
throat  complications  of  the  exanthemata  as  scarlet  fever  and 
measles,  or  occasionally  as  a  traumatic  result  of  galvano-cautery 
to  the  nasal  passages,  or  as  an  accident  after  bathing.  Whatever 
the  cause,  anodyne  ear-drops  of  belladonna  and  opium  not  only 
relieve  pain,  but  often  prevent  an  acute  median  otitis  from  pro- 
ceeding to  suppuration.  The  membrane  should  always  be  care- 
fully inspected  whenever,  in  the  course  of  acute  throat  diseases, 
ear-ache  is  complained  of,  and  so  soon  as  there  is  distinct  evidence 
of  acute  suppuration  the  membrane  should  be  artificially  per- 
forated, and  gentle  soothing  medication  only  pursued.  It  is  to  be 
noted  that  while  an  incised  membrane  almost  always  heals,  such 
a  result  is,  to  say  the  least,  doubtful  if  it  is  allowed  to  rupture. 
Cassells  therefore  justly  gave  the  name  of  '  Conservative  Aural 
Surgery '  to  the  course  here  recommended.  Chronic  cases  may 
be  treated  on  the  same  lines  as  the  non-suppurative  as  regards 
the  Eustachian  orifice,  but  we  may  now  go  further  and  inject 
sprays  and  medicated  solutions  by  Politzer,  or  by  the  catheter  in 
obstinate  cases.  Whilst  treatment  by  way  of  the  Eustachian 
orifice  is  being  pursued,  the  tympanic  disease  must  also  be  ener- 
getically attacked  through  the  meatus.  This  passage  should 
always  be  washed  out  with  warm  water,  or  mild  antiseptic  lotions, 
before  the  application  of  detergent  or  astringent  drops. 

The  tube  should  always  be  freed  after  syringing,  either  by 
Politzer's  or  other  mode  of  inflation  ;  and  finally,  treatment  should 
aim  at  preventing  retention  of  discharge ;  for  extension  to  the 
mastoid  cells,  meninges,  and  brain  often  results  from  the  opposite 
practice  of  too  strong  astringents  or  detergents,  and  hence  the 
traditional  objection  to  stop  a  discharge  from  the  ears. 

In  very  small  perforations  the  opening  may  require  to  be  en- 
larged, and  the  disease  be  treated  by  the  aid  of  the  intra-tympanic 
syringe  in  conjunction  with  Siegle's  exhaustion  apparatus. 

Besides  the  forms  of  abscess  just  alluded  to,  the  other  ordinary 
complications  of  otorrhoea  are  gramdations,  polypi,  external  otitis, 
eczema,  and  ostoses.  These  results  only  occur  after  long-standing 
suppurative  catarrh,  and  are  but  remotely  connected  with  throat- 
deafness. 


FORMULAE  FOR  REMEDIES. 


As  previously  stated  in  Chapter  VIL,  many  of  these  formulos  are  identical 
with  those  contained  in  the  Throat  Hospital  Pharmacopma,  to  which  the 
reader  is  referred  for  further  interesting  and  serviceable  details.  The  list 
here  given  is  not  very  extensive,  but  it  includes  all  those  remedies  which  I 
have  found  to  possess  distinct  therapeutic  action.  The  formulae  are  arranged 
mainly  in  the  order  in  which  they  are  considered  in  the  Chapter  on  tlie 
'  Therapeutics  of  Throat  Diseases.' 

The  number  of  the  page  at  the  heading  of  each  separate  kind  of  remedy, 
refers  to  my  views  regarding  its  value  and  mode  of  employment,  as 
expressed  in  the  text. 

GARGARISMATA— GARGLES.    Page  loi. 

1.  Gargarisma  Acidi  Acetici,  T.H.P. 

^  Acidi  Acetici      ...        ...        ...        ...        ...    fl.  7jijss. 

Glycerini...        ...        ...        ...        ...        ...     fl.  3iij- 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  3^"^- 

Misc. 

Use. — Antiseptic  and  stimulating  when  inflammatory  throat  affections 
complicate  the  exanthemata. 

2.  Gargarisma  Acidi  Carbolici. 

Glycerini  Acidi  Carbolici         ...       ...       fl.  3j.  ad  3ij. 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  3X. 

Misce. 

Use. — Stimulant  and  antiseptic.  Useful  in  cases  of  pharyngitis  sicca, 
and  all  forms  of  ulceration  ;  also  diluted  with  warm  water  as  a  mouth-wash 
in  tonsillitis. 

3.  Gargarisma  Acidi  Nitrici. 

^  Acidi  Nitrici  Diluti    fl.  3j. 

Tincturse  Cinchonas      ...        ...        ...        ...     fl.  3iij- 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  5X. 

Misce. 

Use. — Stimulant  in  cases  of  tertiary  syphilitic  ulceration  of  the  pharynx. 


CyB  DISEASES  OF  THE  THROAT  AND  NOSE. 

4.  Gargarisma  Acidi  Tannici  et  Gallici,  T.H.P. 

Acidi  Tannici     ...        ...        ...        ...        ...    gr.  360. 

Acidi  Gallici      ...        ...        ...        ...        ...    gr.  120. 

Aquae    fi.  5j. 

Misce. 

Use. — This  is  the  preparation  mentioned  at  pages  236  and  258,  for  use 
as  a  styptic  after  excision  of  the  tonsils  or  ablation  of  the  uvula. 

This  mixture  should  be  made  fresh  as  required,  and  in  a  large  tumbler, 
since  the  powders  occupy  considerable  bulk.  The  object  of  the  preparation 
is  that  it  should  be  a  thick  mixture  rather  than  a  solution. 

5.  Gargarisma  Aluminis  cum  Acido  Tannico. 

Aquae      ...        ...        ...        ...        ...       ...      fl.  5x. 

Misce. 

Use. — Astringent  in  ordinary  relaxation  and  congestion  of  the  fauces. 

6.  Gargarisma  Boracis. 

^  Glycerini  Boracis  ...        ...        ...    fi.  3SS.  ad  sjss. 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  gx. 

Misce. 

Use. — Mildly  alkaline  and  astringent. 

7.  Gargarisma  Hydrargyri  Perchloridi. 

Liquoris  Hydrargyri  Perchloridi  (B.P.)  fl.  giii.  ad  5V. 
Aquam    ...        ...        ...        ...        ..         ...  ad  fl.  5X. 

Misce. 

Use. — Stimulant.  In  syphilitic  ulceration  of  the  pharynx.  To  be  used 
rather  as  a  mouth-wash  than  as  a  gargle. 

8.  Gargarisma  Potassae  Chloratis. 

]^  Potassae  Chloratis         ...        ...  gr.  90  ad  gr.  120. 

Glycerini...        ...        ...        ...        ...        ...      fl.  oij- 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  3X. 

Misce. 

Use. — Antiseptic.    Useful  in  disorder  of  the  glandular  secretion. 

9.  Gargarisma  Potassae  Chloratis  c.  Acido  Salicylico. 

^  Potassae  Chloratis  ] 

Acidi  Salicylici   ...  j  ^'  5  •  y  • 

Aquae    fl.  .3X. 

Use. — Antiseptic.  x\lways  recommended  after  excision  of  tonsils  and 
uvula,  and  in  all  forms  of  insanitary  sore  throat. 

10.  Gargarisma  Potassae  Permanganatis. 

^  Liquoris  Potassae  Permanganatis         ...        (B.P.)  fl.  7)}- 
Aquam  destillatam        ...        ...        ...        ...  ad  fl.  5X. 

Misce. 

(jse. — Antiseptic.  In  the  same  proportions,  but  at  a  temperature  of  90" 
to       F.,  this  gargle  may  be  used  as  a  nasal  douche. 


FORMULM  FOR  REMEDIES. 


679 


1 1.  Gargarisma  *  Sanitas  ' 

^  'Sanitas'  ...        ...       ...        ...        ...      fl.  5SS. 

Aquam    ...        ...        ...        ...        ...        ...  ad  fl.  ^x. 

Misce. 

Use. — Antiseptic,  or  as  in  the  last  formula  for  a  nasal  douche. 

TROCHISCI— LOZENGES.    Page  103. 

1 2.  Trochisci  Astringentes  Effervescentes. 

These  were  made,  at  the  suggestion  of  the  author,  by  Mr.  Cooper,  of 
Oxford  Street  (see  British  Medical  Journal^  Jan.  24th,  1874).  Each 
lozenge  contains  i  grain  of  Eucalyptus  and  a  small  quantity  of  powdered 
squill,  combined  with  the  ingredients  of  Cooper's  well-known  effervescing 
lozenge. 

Use. — Astringent  and  sialagogue.  Most  useful  as  voice  lozenges.  One, 
or  a  portion  of  one,  should  be  taken  before  use  of  voice. 

13.  Trochisci  Antimonialis  Compositi  Effervescentes. 

These  lozenges,  also  made  by  Cooper,  contain  in  each  the  ingredients  of 
the  compound  Sub-chloride  of  Mercury  (Plummer's)  pill,  B.P. 

Use. — In  secondary  syphilis  for  the  better  attainment  of  both  local  and 
constitutional  effect. 

14.  Trochisci  Altheae. 

The  ordinary  Guimauve  lozenges  of  commerce. 

Use. — EmoUient.  Valuable  after  excision  of  tonsils  or  uvula,  leaving  as 
they  do  a  soft  pultaceous  layer  over  the  raw  surface. 

15.  Trochisci  Acidi  Carbolici,  T.H.P. 

Each  lozenge  contains  about  i  grain  of  carbolic  acid,  and  is  marked 
C.  A. 

Use. — Antiseptic  and  stimulant.    Serviceable  in  pharyngitis  sicca. 

16.  Trochisci  Eucalypti  Compositi. 

Originally  manufactured  for  the  author  by  Corbyn,  Stacey,  and  Co.  Each 
lozenge  contains  2  grains  of  Chlorate  of  Potash,  i  grain  of  extract  of 
Eucalyptus  rostrata,  \  grain  of  powdered  Cubebs,  with  acid  fruit  paste,  and 
is  marked  C.  E. 

Use. — Largely  employed  by  the  author  for  the  joint  astringent,  sialagogue, 
and  expectorant  action  of  the  various  ingredients  ;  and  preferable  to  many 
lozenges  containing  but  one  active  agent. 

17.  Trochisci  Salini  Astringentes. 

These  lozenges  were  made  to  the  author's  prescription  by  Roberts,  of 
Bond  Street,  as  a  substitute  for  the  above  in  those  cases  in  which  the  fruit 
paste  produces  disorder  of  digestion.  Each  lozenge  contains  2  grains  of 
Chlorate  of  Sodium,  i  grain  of  extract  of  Eucalyptus  rostrata,  \  grain  of 
extract  of  Cubebs,  with  a  basis  of  Liquorice  and  Glyco-gelatine. 

Use. — The  same  as  the  foregoing. 

Note. — The  medicated  pastilles  of  Dr.  Whistler  are  prepared  with  the 
same  intent  of  correcting  the  defects  of  lozenges  mr.de  with  fruit  paste,  but 
are  difficult  of  adoption  for  general  use. 


68o 


DISEASES  OF  THE  THROAT  AND  NOSE. 


1 8.  Trochisci  Expectorantes. 

These  lozenges  are  also  made  for  me  by  Roberts,  and  contain  each  tt^j 
grain  of  Ipecacuanha,  with  a  basis  of  Glyco-gelatine. 
Use. — As  indicated  by  the  title. 

19.  Trochisci  Euonymin  Compositi  Effervescentes  (CooperV 
Use. — Aperient  and  cholagogue. 

20.  Trochisci  Hydrargyri  Sub-Chloridi  Effervescentes  (Cooper). 
Each  lozenge  contains  J  grain  of  Calomel. 

Use. — Aperient  and  cholagogue. 

21.  Trochisci  Guaiaci,  T.H.P. 

Each  lozenge  contains  2  grains  of  Guaiacum,  and  is  marked  G. 
Use. — In  acute  inflammation  of  the  tonsils  and  fauces,  and  generally  for 
*  soreness  '  of  throat. 

22.  Trochisci  Morphiae  et  Ipecacuanhae,  B.P. 

Each  lozenge  contains  3^-  grain  of  Hydrochlorate  of  Morphia  and  grain 
of  Ipecacuanha. 

Use. — For  allaying  irritable  cough,  and  assisting  expectoration  in  laryngeal 
and  bronchial  catarrh. 

23.  Trochisci  Krameriae,  T.H.P. 

Each  lozenge  contains  3  grains  of  extract  of  Rhatany,  and  is  marked  R. 
Useful  when  an  astringent  only  is  required.  In  the  practice  of  the  author, 
the  Compound  Eucalyptus  lozenge  is  usually  substituted. 

24.  Trochisci  Potassae  Chloratis  Effervescentes  (Cooper). 
Each  contains  3  grains  of  Chlorate  of  Potash. 

Use. — Antiseptic,  stimulant,  and  sialagogue.  Most  useful  in  cases  of 
foetid  breath,  dependent  on  pharyngeal  and  laryngeal  disease.  They  are 
but  of  little  use  where  the  disease  is  situated  in  the  nasal  passages. 

25.  Trochisci  Ammonii  Chloridi  c  Borace  (Roberts). 

Each  lozenge  contains  2  J  grains  of  Chloride  of  Ammonium,  and  of 
Borax,  and  is  mixed  with  Liquorice  and  Glyco-gelatine,  the  former  of 
which  effectually  masks  the  taste  of  the  Ammonia  Salt. 

The  same  lozenge  is  made  by  Wyeth,  but  although  very  effective,  is  too 
nauseous  to  find  general  favour. 

Use. — Most  valuable  as  a  voice  lozenge,  and  as  a  resolvent  of  catarrhal 
congestion  of  the  pharynx. 

26.  Trochisci  Cocainae. 

These  lozenges,  each  of  which  contains  \  grain  of  Cocaine,  were  made  by 
Messrs.  Savory  and  Moore  for  my  colleague,  Mr.  Carmalt  Jones,  who 
was  the  first  to  suggest  their  administration  in  this  form. 

Use. — In  diseases  of  the  throat  of  a  painful  nature,  and  as  a  local 
anaesthetic  previous  to  examinations  and  operations. 

VAPORES-INHALATIONS.    Page  104. 

A.— STEAM  INHALATIONS. 

27.  Vapor  Amyl  Nitritis,  T.H.P. 

^  Amyl  Nitritis    fl.  3j. 

Spiritus  rectificati   ad  fl.  siij. 

Misce. 


FORMULM  FOR  REMEDIES. 


A  teaspoonful  in  a  pint  of  water  at  ico°  F.  for  each  inhalation,  or  on  a 
cone  of  blotting-paper. 

C/se. — Anti-spasmodic.  Valuable  in  some  cases  of  asthma  and  spasm  ut 
the  glottis. 

28.  Vapor  Ammoniae,  T.H.P. 

^  Liquoris  Ammoniae  (B.P.,  sp.  gr.  '959), 

Aquae      ...        ...        ...        ...        ...        aa.  fl.  5jss. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  100°  to  120°  F.  for  each  inhalation. 

Use. — Powerfully  stimulant ;  useful  in  chronic  laryngitis,  and  in  functional 
aphonia.  In  all  cases  this  inhalation  should  be  used  sparingly,  as  consider- 
able reaction  and  congestive  relaxation  follow  its  employment.  Various 
essential  oils  may  with  advantage  be  combined. 

29.  Vapor  Benzoini,  T  H.P. 

^  Tincturae  Benzoini  Compositae  ...        ...        ...     fl.  5iij. 

A  teaspoonful  in  a  pint  of  water  at  130°  to  150°  F.  for  each  inhalation. 
Use. — A  valuable  sedative  in  acute  inflammations   of  pharynx  and 
larynx. 

30.  Vapor  Benzoini  c.  Chloroformo. 

^  Tincturae  Benzoini  Compositae  ...        ...        ...     fl.  siij. 

Chloroformi       ...        ...        ...       ...        ...  lH^xxv. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 
Use. — Sedative. 

31.  Vapor  Benzoini  c.  Oleo  Pini  Sylvestris. 

$1  Tincturae  Benzoini  Compositae  ...        ...        ...   fl.  3xxij. 

Olei  Pini  Sylvestris       ...        ...        ...        ...      fl.  3ij. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 
Use. — Mildly  stimulant.    Of  service  in  the  mucous  stage  of  inflammation 
of  the  pharynx  or  larynx. 

32.  Vapor  Benzol. 

^  Benzol    ...        ...        ...        ...        ...        ...      fl.  3ij- 

Olei  Cassiae       ...        ...        ...        ...        ...  lT]^vj. 

Magnesiae  Carbonatis  Levis      ...       „..        ...     gr.  60. 

Aquam    ...        ...        ...        ...        ...  ad  fl.  siij. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 
Use. — Similar  to  Benzoin,  but  rather  more  stimulating.    Employed  in 
hospital  practice  on  account  of  the  lessened  cost. 

33.  Vapor  Benzol  c.  Aldehydo. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 

^  Aldehydi    fl.  ^ss. 

Vaporem  Benzoli          ...        ...        ...  ad  fl.  5iij. 

Use. — Mildly  stimulant.  The  Aldehyde  is  indicated  in  cases  of  arrested 
mucous  secretion. 


682  DISEASES  OF  THE  THROAT  AND  NOSE. 

34.  Vapor  Conii,  T.H.P. 

^  Sodse  Carbonatis  Exsiccatae      ...        ...       ...     gr.  20. 

Aqiise  (140°  F.)...    fl.  ^xx. 

Solve  et  adde 

Succi  Conii        ...        ...        ...        ...       ...      fl.  5ij. 

The  vapour  to  be  inhaled. 
Use. — Sedative. 

35.  Vapor  Creasoti. 

|l  Creasoti   fl.  355. 

Magnesias  Carbonatis  Levis      ...        ...        ...     gr.  90. 

Aquam  ad  fl.  giij. 

Misce. 

A  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 

Use. — Stimulant.    In  chronic  congestion  of  the  larynx  and  in  ozsena. 

36.  Vapor  Eucalypti. 

Olei  Eucalypti   fl.  5j.  ad  5iij. 

Magnesise  Carbonatis  Levis      ...        ...  gr.  30  ad  gr.  90. 

Aquam  ad  fl.  siij. 

Use. — An  agreeable  stimulant,  with  sedative  effect  in  laryngeal  inflam- 
mation of  a  subacute  character. 

37.  Vapor  Lupuli. 

^  Extracti  Lupuli  ...        ...        ...        ...        ...     gr.  60. 

(Treated  as  for  coniurn  inhalation,  Formula  34.) 

Use. — Sedative.    Especially  useful  in  laryngeal  phthisis  and  cancer. 

The  vapour  of  oil  of  hops,  as  recommended  in  the  Throat  Hospital 
Pharmacopeia^  is  very  irritating,  and  far  from  sedative.  Although  incon- 
venient on  account  of  its  bulk,  the  old  inhalation  prepared  by  macerating 
hops  in  hot  water  was  much  more  soothing. 

38.  Vapor  Terebenae,  T.H.P. 

$0  Terebenae  Puras  ...        ...        ...        ...        ...      fl-  5ij. 

Magnesiae  Carbonatis  Levis      ...        ...        ...     gr.  60. 

Aquam    ...        ...        .  .        ...        ...  ad  fl.  5iij- 

Misce. 

Use. — Sedative  and  antiseptic  in  phthisis,  and  a  mild  stimulant  in 
catarrhal  laryngitis. 

39.  Vapor  Pini  Sylvestris,  T.H.P. 

%  Olei  Pini  Sylvestris    fl.  5ij- 

Magnesiae  Carbonatis  Levis      ...        ...        ...     gr.  60. 

Aquam    ...        ...        ...        ...        ...        ...adfl.  siij. 

Misce. 

A.  teaspoonful  in  a  pint  of  water  at  140°  F.  for  each  inhalation. 
Use. — A  mild  but  useful  stimulant  and  resolvent. 

40.  Vapor  Pini  Sylvestris  c.  Camphora. 

Fiat  ut  supra  cum  Camphoras   gr.  5. 

Use. — More  stimulant  than  the  foregoing. 

Note. — Any  of  the  above,  excepting  those  of  Formulae  27  and  28,  may 
be  used  with  Lee's  Steam  Draught  Inhaler  (page  107). 


FORMULA  FOR  REMEDIES. 


683 


COLD  INHALATIONS. 

These  refer  chiefly  to  those  of  the  vapour  of  Neutral  Chloride  of 
Ammonium  (page  108). 

Many  of  the  essential  oils  applicable  for  steam  inhalations  may  be  dis- 
solved in  spirit  and  added  to  the  water-chamber  through  which  the 
nascent  ammonia  passes.  In  this  connection  I  also  employ  Ozonic  Ether, 
and  the  following  is  a  type  of  a  formula  for  this  class  of  inhalations  : 

41. 

$1  Olei  Eucalypti       )  n  7. 

Olei  Pini  Sylvestris /  aa.  n.  53. 

Etheris  Ozonici  \  "a  fl  x* 

Spiritus  Vini  Rectificati j         ***        *"        •••^a.  .5x3. 

Misce. 

A  teaspoonful  to  be  added  to  the  water-chamber  of  the  neutral  ammonia 
inhaler. 

Use. — Serviceable  as  a  stimulant  to  promote  secretion  in  chronic  catarrhal 
inflammations  of  the  pharyngeal  and  naso-pharyngeal  passages.  The  Ozonic 
Ether  reheves  spasmodic  dyspnoea  in  cases  of  stenosis,  etc. 

NEBULA -ATOMIZED  FLUID  INHALATIONS.    Page  109. 

These  are  chiefly  recommended  for  pharyngeal  and  nasal  diseases. 
The  amount  prescribed  is  the  maximum  to  be  used  for  any  one  inhala- 
tion.   A  less  quantity  is  often  sufficient. 

42.  Nebula  Acidi  Carbolici,  T.H.P. 

^  Acidi  Carbohci   gr.  3. 

Aquae  destillatse  ...        ...        ...        ...        ...       fl.  5j. 

Solve. 

Use. — Stimulant  and  antiseptic,  where  there  is  deficient  mucous 
secretion. 

43.  Nebula  Acidi  Hydrocyanici  Diluti. 

^  Acidi  Hydrocyanici  diluti        ...        ...        ...  Jss. 

Aquam  destillatam        ...        ...        ...        ...       fl.  5j. 

Misce. 

Use. — Only  about  a  drachm  to  be  used  at  a  time  as  a  sedative  in  the 
cough  of  phthisis  and  in  carcinoma. 

44.  Nebula  Acidi  Lactici. 

^  Acidi  Lactici   fl.  5].  ad  fl.  5ij. 

Aquam  destillatam       ...        ...        ...        ...       fl.  5j. 

Misce. 

6^^^.— Of  great  service  in  diphtheria ;  it  appears  to  have  the  eflect  of  dis- 
solving the  membranous  exudation,  and  is  employed  by  me  to  the  exclusion 
of  all  other  local  treatment  for  that  purpose.  When  applied  with  the  brush 
it  may  be  used  to  the  strength  of  equal  proportions  of  the  acid  and  water. 

45.  Nebula  Alkalina. 

R  Sodse  Bicarbonatis^ 

Sodse  Biboratis     /  aa.  gr.  8. 

Aquae  destillatae   fl,  ~i 


684 


DISEASES  OF  THE  THROAT  AND  NOSE. 


46.  Nebula  Calcis,  T.H.P. 

•     Liquoris  Calcis,  (/.s. 
Use. —  Of  some  repute  as  a  resolvent  in  diphtheria. 

47.  Nebula  Cocainae. 

5o  Cocainse  Hydrochloratis  ...        ...  gr.  25.  ad  gr.  50. 

Aquae    fl.  5]. 

Misce. 

Use. — As  local  anaesthetic  to  be  employed  for  a  few  seconds  prior  or 
subsequent  to  operations  on  the  throat  or  nose.  In  the  latter  case  it  is 
better  to  apply  pledgets  of  absorbent  wool  soaked  v/ith  the  stronger  solution 
inside  the  nostrils,  there  to  be  retained  for  twenty  to  thirty  minutes. 

48.  Nebula  Morphiae  Bi-Meconatis. 

Liquoris  Morphioe  Bi-Meconatis  (Squire)       ...  V(ly. 
Aquae      ...        ...        ...       ...        ...        ...     fl.  ^ss. 

Misce. 
Use. — Sedative. 

49.  Nebula  Potassse  Chloratis. 

^  Potassae  Chloratis         ...        ...        ...        ...     gr.  20. 

Aquae  destillat^  ...        ...        ...        ...        ...       A.  ^i- 

Misce. 

Use. — Antiseptic  and  stimulant. 

50.  Nebula  Sodii  Salicylatis. 

1^  Sodii  Salicylatis  ...        ...        ...        ...        ...     gr.  20. 

Aquae  destillatae ...       ...       ...       ...       ...       A- 5j. 

Misce. 

Use. — Resolvent  and  antiseptic. 

51.  Nebula  Zinci  Sulpho-Carbolatis. 

^  Zinci  Sulpho-carbolatis  ...        ...        ...        ...       gr.  5. 

Aquae  destillatae .. .        ...        ...       ...        ...        A- .^j. 

Misce. 

Use. — Astringent  and  antiseptic. 

FUMING  INHALATIONS.    Page  114. 

The  ordinary  method  of  employing  these  inhalations  is  to  steep  unsized 
white  or  brown  paper  in  aqueous  solutions  of  nitrate  of  potash  of  three 
strengths,  viz.,  30  grains,  40  grains,  and  60  grains  to  the  ounce. 

Such  is  the  basis  of  almost  all  forms  of  asthma  cures.  The  most  useful 
addition  in  the  way  of  drugs  containing  volatile  principles  are.  Eucalyptus, 
Santal,  and  Stramonium. 

Another  form  of  fuming  inhalation  is  that  of  sublimed  calomel,  as 
figured  and  described  at  page  115. 

DRY  INHALATIONS.    Page  107. 

These  preparations  are  employed  by  me  in  connection  with  Oro-nasal  in- 
halers, and  are  indicated  in  cases  of  phthisis,  dry  hot  inhalations  being 
generally  impracticable. 

The  following  are  types  : 


FORMULA  FOR  REMEDIES. 


685 


52.  Vapor  Siccus  (Coghill). 

Tincturae  lodi 

Acidi  Carbolici  __ 
Creasoti  (vel  Thymol)   ***        **'        *"  *" 
Etheris  Sulphurici 
Misce. 

Use. — Stimulant  and  antiseptic.  This  is  the  form  recommended  by  Dr. 
Coghill. 

53.  Vapor  Siccus  (L.B.) 

^  Creasoti  ...        ...        ...        ...        ...        ...     fl.  ^ss. 

Olei  Pini  Sylvestris\  __  ^. 

Olei  Eucalypti  j 

Tincturse  Benzoini  Co.  ...        ...        ...        ...  3ij' 

Misce. 

Use. — Stimulant,  but  less  likely  to  provoke  cough  than  the  above. 

Note. — The  vapours  of  Pine  Oil,  Eucalyptus  Oil  and  Pure  Terebine  can 
also  be  inhaled,  uncombined,  either  from  the  oro-nasal  inhaler  or  from  a 
piece  of  lint. 

PIGMENTA— FLUIDS  FOR  EXTERNAL  AND 
INTERNAL  APPLICATION. 

A.  External.    Page  121. 

54.  Liquor  Epispasticus,  B.P. 

55.  Linimentum  lodi  vel  Tinctura,  B.P. 

56.  Linimentum  Sinapis  Compositum,  B.P. 

57.  Pigmentum  Chloral  c.  Camphora. 

^  Camphorae  (reduced  to  fine  powder  with  a  few^ 

drops  of  rectified  spirit)  I    aa.  jss. 

Chloral  Hydratis  ) 
Misce  bene. 

This  preparation,  which  is  of  American  origin,  was  introduced  to  the  pro- 
fession in  England  mainly  by  the  author  in  1874.  (See  British  Medical 
Journal^  March  7th,  1874.) 

Use. — Employed  as  an  external  anaesthetic  in  neuralgic  affections  of  the 
throat,  and  indeed  for  any  form  of  pain  which  can  be  relieved  by  external 
means. 

B.  Internal.    Page  124, 

58.  Pigmentum  Acidi  Carbolici. 

15  grs.  to  30  grs.  in  the  ounce  of  distilled  water. 

59  Pigmentum  Acidi  Lactici. 

Equal  parts  of  the  ingredient  and  distilled  water. 
Use. — In  diphtheria.     This   solution    is    much    stronger   than  that 
ordinarily  recommended.    (See  Formula  44.) 
59*.  Pigmentum  Aluminii  Chloridi. 

10  grs.  to  30  grs.  to  the  fluid  ounce  of  distilled  water. 
60.  Pigmentum  Argenti  Nitratis.    Page  296. 

10  grs.  to  60  grs.  in  the  fluid  ounce  of  distilled  water. 


686 


DISEASES  OE  THE  THROAT  AND  NOSE. 


6 1.  Pigmentum  Cupri  Sulphatis. 

lo  grs.  to  20  grs.  in  the  fluid  ounce  of  distilled  water. 

62.  Pigmentum  Ferri  Perchloridi. 

20  grs.  to  90  grs.  in  the  fluid  ounce  of  distilled  water. 

63.  Pigmentum  lodi  c.  Acido  Carbolico. 

^  lodi,  Acidi  Carbolici,  Potassii  lodidi   ...        ...  aa.  gr.  4. 

Glycerini ...        ...        ...        ...        ...        ...     fl.  3SS. 

Aquarn  destillatam        ...        ...        ...        ...      ad  sj. 

Misce. 

l/se. — In  slight  chronic  pharyngitis  and  in  secondary  syphilis. 

64.  Pigmentum  lodoformi  vel  lodol. 

5o  lodoformi  vel  lodol      ...        ...        ...        ...  3j- 

^theris  Communis       ...        ...        ...        ...      ad  33. 

Use. — Dissolve  by  adding  the  iodoform  or  iodol  gradually  to  the  ether 
with  frequent  shaking.  Useful  in  reducing  naso-pharyngeal  congestions  and 
in  granular  pharyngitis.  The  iodol  is  preferable  to  the  iodoform,  on  account 
of  the  smell,  but  is  hardly  so  active  in  efl"ect. 

65.  Pigmentum  Zinci  Chloridi. 

10  grs.  to  30  grs.  in  the  ounce  of  distilled  water. 

66.  Pigmentum  Zinci  Chloridi  c.  Morphia. 

^  Zinci  Chloridi    ...        ...        ...        ...  gr.  10  to  gr.  30. 

Morphiee  Hydrochloratis  ...        ...        ...       gr.  8. 

Glycerini  |   -.^  -^^^ 

Aquse  destillatsef  "*       *"  ***       '  ^  ' 

Misce. 

Note. — Morphia  gr.  i,  or  Cocaine  gr.  5  to  the  fluid  ounce,  may  be 
added  to  either  the  copper,  iron,  or  zinc  solutions. 

67.  Pigmentum  Ovi  Vitelli. 

$1  Tinctur£e  Benzoini  Compositaj   \  -- 
Tincturae  Camphorse  Compositcej  '  ' 

Tincturae  Belladonnae   ...       ...       •••       •••  5j. 

Misce  et  adde  Vitellum  Ovi  unum. 
Use. — This  preparation  has  been  found  of  great  value  in  cases  of  buccal 
and  lingual  tuberculosis,  as  an  application  to  be  employed  immediately 
before  the  taking  of  food.  It  has  been  somewhat  modified  by  the  addition 
of  Cocaine  since  the  more  general  introduction  of  that  ingredient  into 
practice. 

INSUFFLATIONES— POWDERS  FOR  INSUFFLATION. 

Insufflations  are  used  by  me  in  only  a  modified  degree,  and  are  limited 
in  number  to  the  following  : 

68.  Insufflatio  Zinci  Chloridi. 

I^  Zinci  Chloridi    gr.  5- 

Bismuthi  Oxy-chloridum   ad  3j. 

Misce. 

U'se. — Astringent  and  resolvent. 


FORMULM  FOR  REMEDIES. 


687 


69.  Insufflatio  Zinci  Chloridi  c.  Morphiae  Hydrochlorate. 

1^  Zinci  Chloridi  |  __ 

Morphiae  Hydrochloratis  j  a^..  gr.  5. 

Bismuthi  Oxy-chloridum    ad  5]. 

Misce. 

Use. — Astringent  and  sedative.,  especially  for  relief  of  cough  in  laryngeal 
phthisis. 

70.  Insufflatio  lodoformi  vel  lodol. 

1^  lodoformi  vel  lodol      ...        ...        ...        ...       gr.  5. 

Bismuthi  Oxy-chloridum         ...       ...        ...      ad  sj. 

Misce. 

C^i-^.— Much  recommended  in  cases  of  tuberculous  or  syphilitic  ulcera- 
tion, but  not  largely  employed  in  my  own  practice  in  laryngeal  disease. 

71.  Insufflatio  Cocainae  Hydrochloratis. 

R  Cocainae  Hydrochloratis  ...        ...   gr.  5  ad  gr.  10. 

Bismuthi  Oxy-chloridum          ...        ...        ...      ad  5]. 

Misce. 

Use. — Sedative,  and  serviceable  prior  to  attempts  at  swallowing  for  relief 
of  pain  in  cancer  and  laryngeal  phthisis. 

COLLUNARIA-NASAL  DOUCHES.    Page  119. 

These  preparations  may  be  used  with  either  the  anterior  or  posterior 
nasal  douche.  Ten  ounces  will  usually  be  found  a  sufficient  quantity  to 
use  at  one  time  for  the  anterior  douche,  and  more  than  a  pint  should  never 
be  used.  The  syringe  for  the  posterior  douche  holds  four  ounces,  and 
about  two  syringes  full  are  usually  to  be  employed  on  each  occasion  of 
administration.  In  the  use  of  the  anterior  nasal  douche  on  the  siphon 
principle,  the  vessel  containing  the  fluid  should  not  be  placed  much  above 
the  patient's  head,  or  the  current  will  descend  with  too  great  force.  In 
cases  of  post-nasal  catarrh,  and  in  cases  in  which  use  of  the  anterior 
nasal  douche  seems  to  cause  aural  trouble,  or  where  there  is  a  more  than 
usually  tenacious  secretion  requiring  removal,  the  posterior  nasal  douche 
will  be  found  superior  to  the  anterior. 

All  nasal  douches  should  be  used  at  a  temperature  of  about  95°  F. 

72.  CoUunarium  Acidi  Carbolici. 

R  Glycerini  Acidi  Carbolici         ...       ...        ...       fl.  5j. 

Aquam  tepidam  ...        ...        ...        ...  ad  fl.  3X. 

Use. — Antiseptic  and  detergent. 

73.  CoUunarium  Boracis. 

R  Glycerini  Boracis   fl.  5ss.  ad  fl.  5X. 

Use. — Sedative  and  antiseptic. 

74.  CoUunarium  Potassae  Permanganatis. 

R  Liquoris  Potassse  Permanganatis        ...    fl.  3j.  ad  fl.  gx. 
Use. — Detergent. 

75.  CoUunarium  Sodae  Sulphatis. 

R  Sodae  Sulphatis  ...       ...       ...       ...       ...  gr.  120. 

Aquae    fl-  5V. 

Solve.    To  be  diluted  with  equal  parts  of  hot  water. 
Use. — Detergent. 


688 


DISEASES  OF  THE  THROAT  AND  NOSE. 


76.  Collunarium  *  Sanitas.' 

'Sanitas'     ...        ...        ...        ...    fl.       to  3iv.  ad  fl.  §x. 

C/se. — Antiseptic  and  detergent. 

77.  Collunarium  Zinci  Sulpho-carbolatis,  T.H.P. 

Zinci  Sulpho-carbolatis      ...        ...        ...  gr.  20  ad.  fl.  gx. 

C^se. — Antiseptic. 

78.  Collunarium  Potassae  Chloratis  Compositum. 

R  Potassae  Chloratis  \ 

Sodae  Bicarbonatis t       ...       ...        ...        ...    aa.  5ss. 

Boracis  J 

Sacchari  Albi     ...        ...        ...        ...        ...  5j- 

Misce. 

Directions. — Dissolve  a  teaspoonful  in  5  to  10  ounces  of  water  at 
95"  F.  for  each  douche. 

UNGUENTA-OINTMENTS. 

Ordinary  ointments  for  external  applications  are  not  given — except  the 
first  of  the  following  prescriptions,  which  is  in  use  at  the  Central  London 
Throat  ^nd  Ear  Hospital,  for  the  external  application  to  the  throat  in  cases 
of  tertiary  syphilitic  disease  of  the  larynx.  All  the  other  forms  here  given 
are  for  nasal  diseases,  and  are  used  preferably  to  medicated  bougies  and 
pledgets  of  cotton-wool — the  Buginaria  and  Gossypia  of  the  Throai 
Hospital  PharmacopcBia. — Most  of  the  nasal  ointments  are  employed  by 
me  after  the  use  of  the  douche,  though  sometimes  independently  of  any 
such  treatment. 

79.  Unguentum  Hydrargyri  c.  Belladonna. 

R  Extracti  Belladonnas 

Unguentum  Hydrargyria 

Unguentum  lodi  / 
Misce. 


3j. 

aa.  5SS. 


THE  FOLLOWING  ARE  ALL  FOR  NASAL 
APPLICATION. 

80.  Unguentum  Atropiae. 

P:  Liquon's  Atropiae  Sulphatis,  B.P.        .-.        ...  oj- 

Vasehnum  vel  Lanolinum        ...        ...        ...      ad  53. 

Misce. 

Use. — Sedative  after  application  of  the  galvano-cautery,  and  for  arrest  of 
excessive  nasal  secretion. 

81.  Unguentum  Acidi  Boracici. 

This  ointment,  whether  made  according  to  the  British  Pharmacopoeia  or 
otherwise,  should  be  in  the  proportion  of  about  i  to  6  of  the  medium. 

Use. — Antiseptic,  sedative,  and  '  healing has  proved  serviceable  in  my 
practice  in  nasal  cases  associated  with  cutaneous  eczema. 


FORMULM  FOR  REMEDIES. 


689 


82.  Unguentum  Eucalypti. 

^  Olei  Eucalypti   ...    n^xx.  ad  fl.  3j. 

Vaselinum  vel  Lanolinum        ...        ...        ...      ad  ^j* 

Misce. 

Use. — Antiseptic  ;  employed  for  keeping  the  mucous  membrane  moist  in 
cases  of  dry  catarrh. 

83.  Unguentum  Hydrargyri. 

^  Unguenti  Hydrargyri  Nitratis,  mitius  I 

Unguenti  Hydrargyri  Nitratis,  Oxidi  i  '  '  "*  . 

Vaselinum  vel  Lanolinum        ...        ...        ...      ad  5]. 

Misce. 

Use. — Detergent  in  cases  of  syphilitic  ulceration. 

84.  Unguentum  lodol. 

^  lodol      ...        ...        ...        ...        ...  gr.  10  to  gr.  25. 

Vaselinum  vel  Lanolinum  ...        ...      ad  ^j. 

Carefully  triturate  the  lodol  and  mix. 
Use. — Antiseptic.    This  preparation  has  superseded  that  of  iodoform, 
formerly  recommended. 

85.  Unguentum  Cocainae  Hydrochloratis  c.  Eucalypto. 

R  Cocainse  Hydrochloratis  ...        .  .        ...       gr.  5. 

Olei  Eucalypti   ll^xx.  ad  fl.  3j. 

Vaselinum  vel  Lanolinum        ...        ...        ...      ad  ^j. 

Misce. 

Use. — Beneficial  in  nasal  cases  dependent  on  hypersemic  hypertrophy  of 
the  turbinated  bones,  also  in  nasal  polypus  after  operation,  and  as  a 
preventive  of  sneezing,  and  as  allaying  many  of  the  symptoms  in  hay- 
asthma. 

MISTURiE— MIXTURES. 

86.  Mistura  Aconiti. 

$0  Tincturae  Aconiti         ...        ...        ...        ...  TILxv. 

Aquam    ...        ...        ...        ...        ...        ...  adfl.  3ij. 

Misce. 

A  teaspoonful  for  a  dose,  to  be  given  every  quarter  of  an  hour  for  four 
doses  ;  then  every  half-hour  for  four  doses ;  then  every  hour,  two  hours, 
etc.,  the  intervals  being  increased  as  the  skin  becomes  moist,  and  the 
heart's  action  lowered. 

Use. — Of  great  value  in  reducing  temperature  and  pulse  in  early  stages 
of  inflammatory  affections,  tonsillitis,  etc. 

87.  Mistura  Ammonii  Chloridi  c.  Sodii  lodido. 

R  Ammonii  Chloridi        ...        ...        ...        ...     gr.  20. 

Sodii  lodidi       ...        ...         ..        ...        ...       gr.  3. 

Ext.  Glycyrrh.  Liq.       ...    lT]^xx. 

Aquas    ^j. 

Misce. 

Use. — In  chronic  naso-pharyngitis  associated  wuth  middle-ear  inflamma- 
tion and  tinnitus. 

44 


690 


DISEASES  OF  THE  THROAT  AND  NOSE. 


88.  Mistura  Belladonnae  c.  Opio. 

1^  Tincturae  Belladonnae^  __  ^ 

Tincturae  Opii  j  "' 

Aquam  Camphorae       ...       ...       ...       ...  ad  fl.  ?j- 

Misce. 

U'se. — In  catarrhal  conditions  causing  coryza.  Will  often  arrest  a 
cold  in  the  head  if  commenced  on  first  approach  of  symptoms.  For 
this  purpose  it  should  be  taken  between  meals,  say  at  11  a.m.  and  4  p.m. 

89.  Mistura  Expectorans. 

${3  Ammoniae  Carbonatis    ...        ...        ...        .,.  TT\^v. 


Tincturae  Scillae  ... 
Tincturae  Camphorae  Compositae 
Syrupi  Zingiberis 
Infusum  Serpentariae 
Misce. 

Use. — A  good  expectorant  mixture. 


ad  fl.  3j. 


90.  Mistura  Ferri  Ammoniata. 

R  Tincturae  Ferri  Perchloridi       ...        ...      l\x  ad  T\xx. 

Ammonii  Chloridi        ...        ...        ...  gr.  10  ad  gr.  20. 

Aqus  Chloroformi        ...        ...        ...        ...     fl.  5ss. 

Aquam   ....   ad  fl.  §j. 

Misce. 

Use. — In  naso-pharyngeal  and  aural  catarrh  associated  with  arrjemia 
The  Sal  Ammoniac  appears  to  aid  in  the  assimilation  of  the  Iron. 

91.  Mistura  Hydrargyri  Perchloridi. 

R  Hydrargyri  Perchloridi   gr.  ^^2-  iV- 

Decocti  Cinchonae        ...       ...       ...       ...       A-  Bj- 

Misce. 

Use. — In  tertiary  syphilis. 

92.  Mistura  Hydrargyri  Biniodidi. 

R  Hydrargyri  Perchloridi  ...        ...       ...       ...       gr-  i. 

Potassii  lodidi   ...     gr.  60. 

Tincturae  Cinchonae      ...       ...       ...       ...     fl.  5iv. 

Misce. 

Dose. — One  to  two  teaspoonfuls  thrice  daily. 
Use. — In  tertiary  syphilis. 

In  private  practice  I  find  the  preparation  known  as  Sirop  de  Gibert, 
which  contains  J  of  a  grain  of  Biniodide  of  Mercury  and  8  grains  of 
Iodide  of  Potassium  with  Syrup  in  each  tablespoonful,  a  useful  and 
*  elegant '  mode  of  administering  this  drug. 

93.  Mistura  Potassii  Bromidi. 

R  Potassii  Bromidi   gr.  10  ad  gr.  30. 

Aquae  Camphorae         ...       ...       ...       ...       fl-  5i- 

Misce. 


FORMULAE  FOR  REMEDIES. 


691 


94.  Mistura  Potassii  lodidi. 

R  Potassii  lodidi   ...        ...        ...        ...    gr.  3  ad  gr.  10. 

Spiritus  Ammoniae  Aromaticae  ...        ...        ...  Vfl^xx. 

Infusum  Gentianae  Compositum   ad  fl.  5j. 

Misce. 

Use. — In  tertiary  syphilitic  affections,  etc.  Iodide  of  Sodium,  in  the 
same  or  smaller  doses,  may  be  substituted  for  the  Potassium  Salt  in  those 
cases  in  which  coryza  results  from  use  of  the  latter. 


95.  Mistura  Salina  Aperiens. 

R  Potassse  Nitratis...        ...  ...  ...  ...  gr.  20. 

Magnesiae  Sulphatis      ...  ...  ...  ...  A-  3j. 

Athens  Nitrosi  Spiritus  ...  ...  ...  TT\_yx. 

Aquam  Camphorae       ...  ...  ...  ...  ad  fl.  ^j. 

Misce. 


Use. — A  good  aperient  for  the  commencement  of  many  affections  of  an 
inflammatory  character. 

96.  Mistura  Salina  Aperiens  c.  Ferro. 

R  Ferri  Sulphails  ...        ...        ...        ...        ..        gr.  2. 

Mislurae  Salinas  Aperientis       ...        ...        ...  3]. 

Misce. 

Use. — Combined  aperient  and  tonic.  The  combination  increases  the 
action  of  both. 

97.  Mistura  Sodse  c.  Gentiana. 

R  Sodoe  Bicarbonatis        ...        ...        ...        ...     gr.  25. 

Spiritus  Ammoniae  Aromatici    ...        ...        ...  n\^xx. 

Infusum  Gentianae  Compositum         ...        ...       ad  ^j. 

Misce. 

Use. — Very  valuable  where  there  is  dyspepsia  and  digestive  disturbance, 
as  in  chronic  pharyngeal  inflammations  ;  and  a  good  alkaline  vegetable 
tonic  alter  recovery  from  quinsy,  etc. 

98.  Mistura  Sodae  Salicylatis  Composita. 

R  Sodae  Salicylatis .. .        ...        ...        ...  gr.  10  ad  gr,  25. 

Sodli  Chloratis  ...        ...        ...        ...     gr.  5  ad  gr.  8. 

Spiritus  Chloroformi     ...        ...        ...        ...  n\x. 

Dccoctum  Cinchonae    ...       ...       ...       ...  ad  fl.  3j. 

Misce. 

J^ose. — Every  hour  or  two  until  pain  is  relieved,  when  the  dose  is  to  be 
dinn'nished  and  the  intervals  of  administration  lengthened.  To  this 
mixture  Sulphate  of  Magnesia  may  sometimes  be  usefully  added. 

l/se. — In  tonsillitis,  where  there  is  simultaneous  general  rheumatism  with 
hyperpyrexia. 

99.  Mistura  Terebenae. 

R  Terebenas  Purae  ...        ...        ...       ...       TT|^v.  ad  TTJ^x. 

Pulveris  Tragacanthi  Compositi  ...        ...       gr.  5. 

Aquam  Chloroformi    ad  5i. 

Misce. 


692 


DISEASES  OF  THE  THROAT  AND  NOSE. 


t/i-^f.— Sedative,  expectorant,  and  antiseptic.  Useful  in  subacute  and 
chronic  laryngeal  catarrh. 

100.  Mistura  Tonica. 

R  Ammoniae  Carbonatis    ...  ...     gr.  3  ad  gr.  5. 

Infusi  Quassiae  ...        ...        ...        ...        ...       [[.  ij. 

Misce. 

Use. — Simple  bitter  tonic. 

101.  Mistura  Tonica  c.  Ferro. 

R  Liquoris  Ferri  Perchloridi    ad  TTl^xxx. 

Infusum  Quassise   ad  fl.  5]. 

Misce. 

With  this  mixture  saline  aperients  may  be  advantageously  combined. 

102.  Mistura  Hypophosphitium  Composita. 

R  Sodae  Hypophosphitis 

Calcii  Hypophosphitis  j aa.  gr.  5. 

Infusi  Quassiae  ...        ...        ...        ...        ...       fl.  3i. 

Misce. 

Use. — This  is  the  ordinary  tonic  prescribed  at  hospital  for  phthisis.  It 
is  varied  by  addition  of  strychnia  or  arsenic ;  and  sometimes  the  compound 
syrup  of  the  hypophosphites  is  substituted. 

PILULiE— PILLS. 

105.  Pilula  Expectorans. 

R  Pilulse  Scillse  Compositse         ...        ...        ...       gr.  4. 

Pulveris  Doveri  ...        ...        ...        ...        ..        gr.  2. 

Pilulae  Rhei  Composites  ...        ...        ...       gr.  3. 

M.  ft.  pil.  ij. — Two  pills  to  be  given  night  and  morning,  and,  if  necessary, 
one  or  two  also  at  intervals  in  the  day. 

Use. — These  pills,  which  are  very  similar  to  some  well  known  as  pre- 
scribed by  the  late  Dr.  Billing,  are  most  valuable  in  cases  of  loss  of  singing 
voice  from  simple  catarrhal  causes. 

104.  Pilula  Hydrargyri  Bi-cyanidi,  T.H.P. 

Each  pill  contains  -^o  grain  of  Bi-cyanide  of  Mercury,  with  sugar  of  milk 
and  mucilage. 

Dose. — One  twice  a  day. 

Use. — In  tertiary  syphilitic  affections.  Also  reputed  to  be  of  value  in 
arresting  quinsy. 

105.  Pilula  Hydrargyri  lodidi  Viridis. 

R  Hydrargyri  lodidi  Viridis         ...        ...        ...       gr.  J. 

Extracti  Haematoxyli     ...        ...        ...        ...       gr.  2. 

Extracti  Lactucae  ...        ...        ...        ...       gr.  3. 

Misce.     Fiat  pilulam. 
Use. — In  secondary  and  early  tertiary  syphilitic  affections. 

106.  Pilula  Hydrargyri  Subchloridi  Composita,  B.P. 

Use. — In  secondary  syphilitic  affections  of  the  throat. 


FORMULM  FOR  REMEDIES. 


693 


107.  Pilula  Hydrargyri  c.  Opio. 

R  Pilulae  Hydrargyri         ...        ...        ...        ...       gr.  i . 

Pulveris  Opii      ...        ...        ...        ...        ...       gi".  -4. 

Misce.    Fiat  pilulam. 

108.  Pilula  Calcii  Sulphidi. 

These  are  made  by  Richardson  and  also  by  Kirby,  and  contain  : 
Calcii  Sulphidi   ...         . .        ...        ...      gr.  ^  to  gr.  3. 

Use.— In.  strumous  enlargement  of  glands,  in  chronic  tonsillitis,  furuncles 
of  the  ear,  etc. 

Note. — This  drug  is  also  prescribed  at  the  hospital  in  powders,  and  as  a 
mixture  with  tragacanth  and  cinnamon  water. 

109.  Pilula  Calcii  Sulphidi  c  lodoformi. 

These  consist  of  pills  of  the  same  varying  strength  of  the  first  drug  as  in 
the  foregoing  formula,  combined  with — 

Iodoform  ...        ...        ...        ...      gr.  ^  to  gr.  i. 

Use. — As  the  foregoing.  They  have  proved  serviceable  in  some  cases  of 
soft  goitre. 

no.  Pilula  pro  Dyspepsia. 

R  Quiniae  \ 

Acidi  Carbolici  L  ...        ..,        ...        ...  aa.  gr.  J. 

Extracti  Rhei  j 

Pepsinge  Porci  (Bullock's)        ...        ...        ...     gr.  22-. 

Misce.    Fiat  pilulam. 
Z>ose. — One  before  each  meal  at  which  meat  is  taken. 
Use. — Valuable  in  sluggish  digestions  with  flatulence,  and  especially 
serviceable  for  vocalists,  actors,  and  all  speakers  in  whom  the  digestive 
function  is  frequently  impeded  by  nervousness. 

nr.  Pedes  Camphorse  Mono-bromidi  (Tisy). 

These  perles  (sold  by  Corb>n  and  Co.)  contain  3  grains  of  tne  active 
ingredient  in  hermetically  closed  gelatine  envelopes.  They  are  absolutely 
tasteless,  and  not  larger  than  a  four-grain  pill. 

Dose. — One  every  2  or  3  hours  until  pain  is  relieved.  If  the  tempera- 
ture becomes  lowered,  the  intervals  must  be  increased. 

Use. — In  neuralgic  affections  of  the  larynx. 

ri2.  Pedes  Fern  lodidi  (Tisy). 

The  Iodine  and  Iron  are  separated  in  these  pills,  so  that  combination 
only  takes  place  in  the  stomach  itself,  and  there  is  no  fear  of  previous 
decomposition,  as  with  other  forms  of  this  valuable  remedy.  Each  perle 
contains  the  equivalent  of  one  grain  of  Iodide  of  Iron. 

jDose. — One  three  times  a  day. 

113.  Granulae  Zinci  Phosphidi. 

These  small  pills  contain  grain  of  Phosphide  of  Zinc,  and  ir.  the 
author's  experience  are  quite  equal  in  effect  to,  and  less  likely  to  produce 
eructations  than,  the  pure  phosphorus  in  capsules. 

Dose. — One  three  times  a  day. 


694  DISEASES  OF  THE  THROAT  AND  NOSE. 


VARIiE-VARIOUS. 

1 1 4-  Linctus  Expectorans. 

R  Oxymellis  Scillae 

Tincturse  Camphorse  Compositae 

Spiritus  Ammoniae  Aromatici 

Vini  Ipecacuanhae 
Misce. — A  teaspoonful  for  a  dose. 

115.  Linctus  Sedativus. 

^  Tincturse  Opii 

Acidi  Sulphurici  diluti  ... 

Theriacae  I 

Aquae  J 
Misce. 
Dose. — A  teaspoonful. 

116.  Anti-catarrhal  Smelling  Salts. 

R  Acidi  Carbolici  ...        ...        ...        ...  ...     gr.  30. 

Ammoniae  Carbonatis    ...        ...        ...  ...  ^j. 

Pulveris  Carbonis  Ligni           ...        ...  ...  ^j. 

Olei  Lavendulae  ...        ...        ...        ...  ...  T({xx. 

Tincturse  Benzoini  Compositae  ...        ...  ...     fl.  ^ss. 

Misce. 

The  above  mixture  was  made  as  the  result  of  analysis  of  a  well-known 

patent  remedy  for  colds  in  the  head,  and  is  very  efficacious  in  certain 
catarrhal  conditions  of  the  naso-pharynx. 

117.  Pigmentum  Acidi  Lactici  (Krause). 

Aqueous  dilutions  containing  20,  40,  and  60  per  cent,  of  the  acid  are 
employed  for  faucial  tuberculosis,  and  also  for  lupus.  It  is  recommendea 
to  apply  a  10  per  cent,  solution  of  cocaine  to  the  affected  part;  then  to 
scrape  freely  and  by  means  of  a  brush,  to  apply  with  Jirm?iess  the  pigment 
in  gradually  increasing  strengths  each  alternate  day. 

118.  Pigmentum  Menthol  (Rosenberg). 

This  consists  of  a  mixture  of  20  parts  of  menthol  with  80  of  olive  oil, 
liquid  vaseline,  or  odourless  paraffin  oil.  It  is  amongst  the  most  recent 
topical  applications  recommended  for  laryngeal  tuberculosis,  and  may  be 
applied  by  either  brush  or  spray.  It  is  also  useful  for  reducing  hyper- 
aemia  of  the  turbinate  bodies. 

119.  Pulvis  Menthol  Comp. 

This  consists  of  a  mixture — to  be  used  as  a  nasal  snuff,  or  with  insufflator 
— of  menthol  with  powdered  spermaceti  (where  moisture  is  required),  or  01 
sugar  of  milk  (where  rhinal  flow  is  excessive),  in  the  proportion  of  i  in  30. 

120.  Gossypium  Menthol  (Bullock  &  Co.). 

Wool  impregnated  with  menthol  to  the  extent  of  5  per  cent,  is  employed 
for  nasal  cases  by  introduction  into  the  nostrils,  and  in  the  strength  of  10 
or  20  per  cent,  by  apparatus  for  oro  nasal  respiration  in  cases  of  pharyngeal 
and  laryngeal  inflammation,  especially  those  of  a  tuberculous  character. 

121.  Trochiscum  Menthol  (Christy). 

Antiseptic,  astringent,  and  analgaesic.  Useful  in  most  forms  of  pharyn- 
gitis, and  especially  in  tonsillitis  and  insanitary  forms  of  sore  throat. 


fl.  ^iss. 
fl.  3vj. 
fl.  5SS. 
fl. 


fl.  5j. 
...    fl.  3iss. 

...  aa.  fl.  l). 


PLATES. 


The  Illustrations  are  so  arranged  that  they  can  be  studied  during  perusal 
of  the  text,  referring  to  them  without  the  inconvenience  of  constantly 
turning  the  leaves. 

For  this  purpose  it  is  necessary  only  to  unfold  the  Plate,  and  it  will  then 
lie  beside  the  letter-press. 

A  short  description  of  each  figure  is  given  on  the  page  corresponding  to 
the  Illustration. 


I.  Varieties  in  Form  of  the  Normal  Larynx  as  seen  in  the  figures 
Mirror        -  -  -  -  -  i  to  ii 

II.  Acute,  Subacute,  and  Chronic  Pharyngitis       -  -        12  to  19 

III.  Syphilitic  Disease  of  the  Pharynx        -  -  -       20  to  27 

IV.  Diseases  of  the  Uvula  and  Tonsils      -  -       28  to  35 
V.  Acute  Tonsillitis — Pharyngitis  Sicca — The  Rhinoscopic 

Image  and  Diseases  of  the  Posterior  Nares — Diph- 
theria of  Fauces  and  Nares  -  -  -  -       36  to  43 
VI.  Simple  Inflammations  of  the  Larynx — Traumatic  Laryn- 
gitis— Diphtheria  of  Larynx  -          -          -  -       44  to  55 
VII.  Syphilitic  Laryngitis     -           -           -           -  -       56  to  67 
VIII.  Anaemia  of  the  Larynx — Tubercular  Laryngitis — Disease 

of  the  Laryngeal  Cartilages  -  -  -  -       68  to  79 

IX.  Benign  Neoplasms  in  the  Larynx — Malignant  Disease 

of  the  Pharyngo-Larynx  and  Larynx  -  -       80  to  9 1 

X.  Neuroses  of  the  Larynx  -  -  -  -     92  to  100 

XL  Tuberculous  Laryngitis  -  -  -  -    1 01  to  105 

XIL  Tuberculous  Laryngitis,  etc.     -  -  -  -    106  to  108 

XIII.  Syphilitic  and  Scrofulous  Ulceration  of  the  Pharynx — 

Pharyngitis  Sicca — Epithelioma  of  the  Palate  and 

Tonsil         -  -  -  -  -  -    109  to  114 

XIV.  Diphtheria — Lupus — Sarcoma — Epithelioma,  etc.        -    115  to  121 
XV.  The  Lymphatic  Vessels  of  the  Base  of  the  Tongue, 

Tonsils,    Larynx,    and   Pharynx — Photo-lithograph 

{after  Sappey)  -  -  -  -  -  122 


696 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  1. 

Varieties  of  the  Normal  Larynx  as  seen  in  the  Mirror. 

Fig.  I  represents  the  appearance,  so  far  as  form  is  concerned,  of  a  typical 
larynx  in  the  act  of  deep  inspiration ;  and  Fig.  2  in  that  of  ordinary  phona- 
tion.  The  other  figures  illustrate  variations  in  conformation  of  different 
portions.    (Pages  61  to  67.) 

As  stated  in  the  text,  no  attempt  has  been  made  at  coloration,  either  in 
this  Plate  or  in  Plate  X.,  since  the  tint  of  mucous  membrane  in  different 
individuals  is  as  various  in  grade  as  is  the  complexion  of  the  skin. 

A.C. — Anterior  Commissure  of  the  Vocal  Cords. 

L.G.E.F. — Lateral  Glosso-Epiglottic  Fold. 

S.G.E.F.  (Fig.  7). — Superior  Glosso-Epiglottic  Fold. 

T.E.F.  (Fig.  2).— Thyro-Epiglottic  Fold. 

P.E.F.— Pharyngo-Epiglottic  Fold. 

A.  E.  F.  — Ary-Epiglottic  Fold. 

S.S.E. — Superior  Surface  of  Epiglottis. 

I.S.E. — Inferior  Surface  of  Epiglottis. 

C.E.— Cushion  of  Epiglottis. 

L.E. — Lip  or  Free  Edge  of  Epiglottis. 

V.B. — Ventricular  Bands — formerly  called  False  Vocal  Cords. 

V.M.  (Figs.  I  and  6). — Ventricle  of  Morgagni. 

F.L — Fossa  Innominata. 

C.W. — Cartilage  of  Wrisberg. 

C.S. — Capitulum  of  Santorini. 

LA.F. — Inter-Arytenoid  Fold. 

P.C. — Posterior  Commissure  of  the  Vocal  Cords. 

V.C. — Vocal  Cords. 

V.P.  (Fig.  2). — Vocal  Process. 

C.C. — Cricoid  Cartilage. 

T. — Trachea. 

R.B.— Right  Bronchus. 

L.B. — Left  Bronchus. 

H.F.  (Fig.  2). — Hyoid  Fossa. 

CH. — Cornu  of  Hyoid  Bone. 


PLATE  I. 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  II. 
Diseases  of  the  Fauces  and  Pharynx. 

Fig.  12. — Acute  inflammation  of  the  fauces  and  pharynx.    (Page  189.) 

Fig.  13. — Subacute  inflammation  of  fauces,  occurring  in  a  gentleman, 
set.  42,  of  arthritic  diathesis  and  prone  to  excess  in  stimulants  and  tobacco- 
smoking.    (Page  190.) 

Fig.  14. — Chronic  relaxation  of  velum  with  congestion  of  the  pillars  of 
fauces.  The  thinning  of  the  mucous  membrane  of  the  velum,  without 
much  relaxation  of  the  uvula,  is  also  here  indicated.    (Pages  191  and  234.) 

Fig.  15. — Strumous  thickening  of  fauces  with  similar  disease  in  the  naso- 
pharynx. The  drawing  represents  the  exact  size  of  the  arch  of  the  soft 
palate  in  the  patient,  aet.  17,  to  whom  allusion  is  made  at  page  642.  The 
rhinoscopic  image  is  shown  in  Fig.  41,  Plate  V. 

Fig.  16. — Subacute  inflammation  of  pharynx  with  pustular  eruption  of 
chicken-pox  (page  189).  This  drawing  was  taken  from  a  young  lady,  set.  20, 
seen  October  15,  1877,  in  consultation  with  Mr.  Henry  Bullock. 

Fig.  17. — Secondary  outgrowth  from  velum,  the  result  of  tertiary  ulcera- 
tion. That  on  the  right  of  the  centre  line  is  the  true  uvula  considerably 
relaxed.    (Pages  207  and  209.) 

Fig.  18. — Chronic  pharyngitis  with  venous  congestion  and  glandular 
hypertrophy — occurring  in  a  professional  vocalist  (tenor),  set.  26.  The 
varicose  veins  were  intercepted  at  five  points  by  galvano-caustic  application 
(October  18,  1877).  The  granular  condition  at  once  subsided,  and  the 
patient  regained  his  singing  voice.    (Page  191  et  seq.) 

Fig.  19. — A  similar  condition,  of  much  longer  standing,  occurring  in  a 
lady's-maid,  set.  35.  Cured  by  similar  treatment,  February,  1877.  Was 
known  to  have  remained  well  in  the  following  November.    (Page  191  <?/  seq.) 


PLATE  TI 


700 


DISEASES  OF  THE  THROAT  AND  NOSE, 


PLATE  III. 

Syphilitic  Disease  of  the  Pharynx. 

Fig.  20. — Secondary  congestion  and  mucous  patches  on  velum  and  uvula 
— drawn  from  a  female,  set.  23,  married  five  years,  and  having  a  healthy 
child  nine  months  old.  Primary  infection  probably  five  or  six  months 
previously.    (Page  201  ^^^.) 

Fig.  21. — Secondary  congestive  patches  with  two  small  symmetrical  condy- 
lomata at  edge  of  posterior  pillars  ;  drawn  October  18,  1877,  from  a  female 
patient,  aet.  21.  Squamous  eruption  on  skin.  Primary  disease  probably 
six  or  eight  months  previously.    (Page  201  et  seq.) 

Fig.  22. — Secondary  congestion  with  characteristic  raised  mucous  patches 
on  fauces  and  tonsils;  drawn  September  24,  187 1,  from  a  married  female 
patient,  aet.  28.    (Page  201  et  seq.) 

Fig.  23. — A  typical  case  of  secondary  congestion  with  strikingly  symmetrical 
mucous  patches;  drawn  February,  1874,  from  a  male  patient,  W.  W.,  ?et.  23 
who  had  been  primarily  infected  six  months  previously.    (Page  201  et  seq.) 

Fig.  24. — Tertiary  ulceration  of  right  side  of  pharynx  and  velum,  and  of 
posterior  wall  of  pharynx;  drawn  from  H.  F.,  an  engine-driver,  aet.  27,  who 
had  been  primarily  infected  three  and  a  half  years  previously.  (Page  205 
et  seq.)  In  this  patient  there  was  also  paralysis  of  the  abductor  of  the  left 
vocal  cord. 

Fig.  25. — Active  tertiary  ulceration  of  posterior  pharyngeal  wall,  with  old 
cicatrices  and  cicatricial  outgrowth;  drawn  from  Catherine  P.,  aet.  41,  who 
had  suftered  from  sore  throat  for  more  than  seven  years.    (Page  209.) 

Fig.  26. — Old  perforating  ulcers  of  velum  and  of  right  side  of  pharynx, 
with  cicatricial  outgrowth  in  the  latter  situation.  The  puckered  condition 
of  the  velum  around  the  central  perforation  well  illustrates  nature's  attempt 
to  close  off  the  passage  to  the  posterior  nares.  (Page  209. )  The  laryngeal 
condition  of  this  patient,  Edward  F.,  aet.  53,  is  delineated  in  Fig.  56, 
Plate  VIII. 

Fig.  27. — Congenital  tertiary  ulceration;  taken  from  a  female  patient, 
aet.  15,  March,  1874,  who  had  suffered  also  from  double  interstitial  keratitis, 
for  which  iridectomy  had  been  performed  on  one  eye.    (Page  209,) 


PLATE  111 


702 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  IV. 
Diseases  of  the  Uvula  and  Tonsils. 
Fig.  28. — Acute  oedema  of  uvula.    (Page  231.) 

Fig.  29,  — Chronic  inflammation  of  uvula  with  relaxed  mucous  membrane, 
which  is  seen  to  be  slightly  bifurcated.  (Pages  232  and  234.)  Drawn 
from  W.  P.,  aet.  31,  painter,  July  11,  1877. 

Fig.  30. — Warty  growth  attached  by  long  membranous  pedicle  to  uvula, 
and  causing  severe  dyspnoea;  removed  December  4,  1876,  with  immediate 
relief.    (Page  238.) 

Fig.  31. — Acute  inflammation  (quinsy)  of  left  tonsil  on  the  fourth  day. 
The  uvula  is  seen  characteristically  lying  on  the  swollen  gland.    (Page  243.) 

Fig.  32. — Chronic  scrofulous  hypertrophy  of  tonsils,  occurring  in  a  lad, 
aet.  17,  sent  for  operation  by  Dr.  Dobell.  The  uvula  is  also  relaxed  and 
rather  nodular.    (Pages  231  and  252.) 

Fig-  33- — Chronic  inflammatory  hypertrophy  of  tonsils,  the  result  of 
repeated  attacks  (twelve)  of  quinsy;  occurring  in  a  male  patient,  aet.  31. 
(Page  252.) 

Fig.  34. — Carcinoma  of  tongue  invading  left  tonsil.  (Case  alluded  to  at 
page  261.) 

Fig.  35. — Lympho  sarcoma  of  right  tonsil.    (Case  detailed  at  pag<^  262.) 


704  DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  V. 

Acute  Tonsillitis — Pharyngitis  Sicca — The  Rhinoscopic  Image,  and 
Diseases  of  the  Posterior  Nares — Diphtheria. 

Fig.  36. — Acute  inflammation,  with  oedema  of  left  tonsil  and  of  uvula, 
occurring  in  a  gentleman,  aet.  22  ;  drawn  November  26,  1876.  The  parents 
of  this  patient  were  first  cousins,  and  the  darthous  diathesis  was  strongly 
evidenced  on  both  sides.  The  case  was  treated  by  aperients  with  colchicum, 
and  suppuration  was  arrested.    (Page  232.) 

Fig.  37. — Pharyngitis  sicca,  with  dry  post-nasal  catarrh  and  ozaena, 
occurring  in  a  patient,  aet.  27,  whose  sister  also  suffered  from  the  same 
complaint.  (Pages  197  and  640.  It  is  very  difficult  to  represent  the  dry 
glazed  condition  of  the  posterior  pharyngeal  wall,  and  the  attempt  to  do 
so  has  been  but  partially  successful.  A  delineation  of  this  disease  is 
repeated  in  Fig.  iii,  on  Plate  XIII. 

Fig.  38. — The  normal  rhinoscopic  image.    (Pages  85  and  87.) 

Fig.  39. — Tertiary  ulceration  of  the  posterior  nares,  in  which  case  there 
was  also  entire  destruction  of  the  soft  palate,  and  ulceration  of  the  covering 
of  the  whole  of  the  roof  of  the  mouth.  A  Eustachian  catheter  introduced 
into  the  anterior  nostril  in  the  ordinary  way  is  seen  making  its  exit,  and 
indicates  how  much  normal  tissue  has  been  destroyed.    (Page  205.) 

Fig.  40. — Tertiary  ulcerations  on  the  posterior  wall  of  the  velum  prior  to 
perforation  on  the  buccal  surface.    (Page  205.) 

Fig.  41* — Rhinoscopic  image  of  case,  the  faucial  appearance  of  which  is 
depicted  in  Fig.  15.  In  this  view  the  granulations  at  the  vault  of  the 
pharynx  and  the  new  growth  on  each  side  of  the  vomer  are  depicted. 
(Page  640.) 

Fig.  42. — Diphtheria,  occurring  in  a  child,  ast.  4  years.  The  right  side 
of  the  throat  was  first  attacked,  and  the  false  membrane  in  this  situation  is 
seen  to  be  of  a  brownish  hue,  while  that  more  recently  exuded  on  the  left 
tonsil  and  uvula  is  of  characteristic  greyish-white  colour.  At  the  lower 
portion  of  the  left  tonsil  a  bleeding  ulcerated  patch  may  be  noticed,  from 
which  the  membrane  had  just  been  removed.  The  laryngeal  appearance, 
taken  at  the  same  time,  is  depicted  in  Fig.  55,  Plate  VI.  (Pages  346 
and  350.) 

Fig.  43. — The  rhinoscopic  image  of  the  same  patient  forty-eight  hours 
later.  (Page  349.)  This  view  was  taken  very  shortly  after  death.  The 
post-mortem  appearance  is  delineated  on  page  346  and  in  Fig.  117, 
Plate  XIV. 


PLATE  ¥. 


7o6 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  VT. 

Non-specific  Inflammations  of  the  Larynx,  etc. 

Fig.  44. — Acute  submucous  inflammation  of  the  larynx. — General  oedema. 
(Page  303.)  Such  an  amount  of  oedema  is  seldom  seen  in  one  case,  unless 
it  be  the  result  of  inflammation  following  typhus  or  other  similar  toxic 
cause.  More  generally  the  epiglottis  or  one  ary-epiglottic  fold  is  infiltrated, 
as  in  the  following  drawing. 

Fig.  45. — CEdema  of  right  side  of  epiglottis  and  right  ary-epiglottic  fold. 

Fig.  46. — The  same,  twelve  hours  after  scarification.    (Page  308.) 

Fig.  47. — Infra-glottic  oedema.  This  condition  is  generally  at  first  the 
result  of  acute  inflammation ;  but  it  is  also  seen  to  last  much  longer  than 
when  occurring  above  the  vocal  cords.  When  it  thus  assumes  a  subacute 
or  chronic  form  it  often  gives  rise  to  respiratory  symptoms  of  the  gravest 
nature.    (Page  304.) 

Fig.  48. — Mucous  inflanmiation  of  larynx,  especially  of  both  vocal  cords. 
(Page  277.) 

Fig.  49. — Mucous  inflammation  of  right  ventricular  band  and  of  epiglottis. 
(Page  277.) 

Fig.  50. — Chronic  inflammation  of  right  vocal  cord,  the  vocal  process 
standing  out  as  a  white  prominence.    (Page  289.) 

Fig.  51. — Mucous  inflammation  of  the  larynx,  with  pustules  of  chicken- 
pox,  occurring  in  the  patient  whose  pharyngeal  condition  under  similar 
circumstances  is  depicted  in  Fig.  16,  Plate  II.    (Page  275.) 

Fig.  52. — Chronic  laryngitis,  with  congestion  of  the  vocal  cords  and 
arytenoid  cartilages,  and  superficial  ulceration  of  the  cords  at  the  vocal 
process.  This  drawing  was  made  from  the  larynx  of  a  clergyman  engaged 
also  in  a  school,  set.  30,  who  had  been  hoarse  on  and  off  for  six  years. 
Local  treatment,  with  complete  rest  of  the  voice  for  eight  months,  effected 
a  cure  of  the  congestion  and  ulceration  ;  but  the  voice,  although  rendered 
serviceable,  never  regained  purity  of  tone.    (Page  289.) 

Fig.  53. — Glandular  laryngitis,  also  occurring  in  a  young  clergyman  of 
very  delicate  family  history,  but  without  any  defined  pulmonary  disease. 
He  passed  two  winters  abroad  with  great  benefit,  and  the  larynx  improved; 
but  the  catarrhal  tendency  remained,  and  was  easily  excited  to  recur. 
(Page  289.) 

Fig.  54. — Traumatic  subacute  laryngitis,  from  a  somewhat  common  cause, 
namely,  lodgment  of  a  foreign  body — in  this  instance  a  pin — in  the  right 
hyoid  fossa.    (Page  306.) 

Fig.  55. — Diphtheria  in  the  larynx,  taken  from  the  same  case  as  that 
which  illustrates  the  appearance  in  the  pharynx  and  posterior  nares  (Figs. 
42  and  43,  Plate  V.,  and  pae;e  346.) 


PLATE  VI. 


Eig.45. 


Pig.  46 


Fig.  49. 


Eig.  50 


^ig.  51. 


Fig.  52 


-lig.  53 


Fig.  54. 


Fig.  55 


7o8 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  VII. 
Syphilitic  Laryngitis 
(Chapter  XVIII.,  pages  380  to  398.) 

Fig.  56. — Secondary  syphilis  in  larynx,  with  mucous  patches  on  the  epiglottis  and  in 
the  inter-arytenoid  space.  The  mottled  appearance  of  the  vocal  cords  may  be  observed 
in  this  and  the  following  figure.    (Page  380.) 

I^^S-  57- — Secondary  syphilitic  congestion  of  the  vocal  cords,  with  unevenness  of  out- 
line hardly  amounting  to  ulceration,  and  condylomata  in  the  inter-arytenoid  fold. 
(Page  382.) 

Fig.  58. — Syphilitic  congestion  of  larynx,  especially  of  right  side,  with  ulceration, 
somewhat  symmetrical,  of  the  ventricular  bands,  and  of  the  left  vocal  cord.  Here 
again  is  seen  a  more  completely  organized  new  growth  in  the  posterior  commissure. 
(Page  381.) 

Fig-  59- — Acute  inflammation  and  ulceration  of  the  right  ventricular  band  and  right 
vocal  cord,  in  a  patient  long  the  subject  of  syphilitic  laryngitis,  and  subject  to  relapses  on 
reception  of  catarrhal  influences.  A  new  growth  is  seen  beneath  the  cords  at  the  anterior 
commissure.    (Pages  381  and  356.) 

Fig.  60. —  Ulceration  of  the  left  lateral  glosso-epiglottic  and  the  left  pharyngo-epiglottic 
fold,  which  occurred  in  a  male  patient,  set.  44,  first  seen  December  8,  1876,  who  had  been 
married  twenty  years,  and  was  the  father  of  nine  children.  The  symptoms  pointed  some- 
what to  malignant  disease,  in  the  appearance  of  which  there  is  also  some  resemblance 
(see  Fig.  90,  Plate  IX.) ;  but  under  local  treatment  and  iodide  of  potassium  recovery  was 
so  rapid  and  complete  as  to  leave  no  doubt  as  to  its  nature.    (Page  384.) 

Fig.  61. — Characteristic  appearance  of  epiglottis  which  has  been  subject  to  specific 
ulceration  (to  be  seen  also  in  Figs.  65,  66,  and  67),  with  paralysis  of  right  vocal  cord 
from  deposit  around  the  arytenoid  cartilage.  The  drawing  (made  April  6,  1877)  represents 
the  larynx  in  the  act  of  phonation,  and  the  affected  cord  is  seen  to  be  in  cadaveric  position 
(Fig.  92,  Plate  IX.).  The  patient,  set.  53,  had  suffered  from  a  hard  sore  eighteen  years 
previously.  His  pharyngeal  condition  is  seen  in  Fig.  26,  Plate  III.  He  had  been  hoarse 
for  four  months,  but  had  no  difficulty  of  breathing  on  exertion.    (Page  388.) 

Fig.  62. — Acute  tertiary  ulceration  of  the  epiglottis,  with  swelling  ol'  the  ventricular 
bands,  a  small  portion  of  the  right  vocal  cord  only  being  visible. 

Fig.  63. — A  similar  condition  but  less  acute,  with  typical  ulcerations  over  the  arytenoid 
cartilages.  (Page  384')  In  both  these  drawings,  also,  the  typical  character  of  the  thickening 
of  the  epiglottis  and  of  the  ulceration  is  marked  (page  384),  and  comparison  should  be 
made  with  Figs.  44,  73,  74,  75,  and  89,  where  this  part  is  so  affected  from  other  causes. 

Fig.  64. — Total  destruction  of  the  left  half  of  the  epiglottis,  with  paralysis  of  left  vocal 
cord  and  outgrowths  from  the  pharyngeal  wall.    (Page  384.) 

Fig.  65. — Stenosis  from  deposit,  with  adhesion  at  the  anterior  portion  of  the  vocal 
cords,  and  in  a  less  degree  at  the  posterior  commissure.  The  patient  from  whom  this 
drawing  was  made,  had  tracheotomy  performed  at  a  general  hospital  three  years  ago,  but 
the  tube  was  removed  without  a  laryngoscopic  examination.  The  operation  had  therefore 
to  be  repeated.    (Page  388.) 

Fig.  66. — Stenosis  of  the  larynx  in  a  patient,  xt.  35,  on  whom  tracheotomy  was  per- 
formed by  the  author  in  October,  1875.  He  has  continued  wearing  the  tube  with  opening 
in  upper  wall  and  with  open  valve,  and  pursues  his  vocation  as  a  broker. 

Fig.  67. — Atrophy  of  left  vocal  cord  following  extrusion  (after  ulceration)  of  the  left 
arytenoid  cartilage.  Drawn  from  a  patient,  set.  38,  who  had  suffered  from  laryngeal 
syphilis  on  and  off  for  ten  years. 


PLATE  VII. 


Rg.  .62 


Fi^.  63. 


Fig.  64. 


Ei0-.  65. 


Fig.  67. 


HaJVSARD  F^dUSHlNC  UWION  LT? 


7IO 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  VIII. 

Anemia  of  the  Larynx — Tubercular  Laryngitis,  etc. 

(Chapter  XII.,  page  271  ;  XIX.,  page  399  ;  and  XV.,  page  311.) 

Fig.  68. — Anaemia  of  the  larynx,  with  feeble  adductive  power  of  vocal 
cords.    (Page  271,) 

Fig.  69. — Appearance  of  the  right  vocal  cord  twelve  hours  after  a  slight 
haemorrhage  from  that  spot.    (Page  273.) 

Fig.  70. — An  early  stage  of  laryngeal  phthisis,  showing  grey  coloration, 
thickening  of  mucous  membrane  over  and  between  arytenoid  cartilages, 
and  ulceration  comparatively  superficial  of  vocal  cords.    (Page  403.) 

Fig.  71. — Characteristic  pyramidal  swellings  of  arytenoid  cartilages;  com- 
mencing degeneration  of  glandules  of  epiglottis  in  laryngeal  phthisis,  in 
male  patient,  aet.  28.    Consolidation  at  apices  of  both  lungs.    (Page  403.) 

Fig.  72. — Similar  thickening,  especially  on  the  right  side,  with  prominence 
of  racemose  glands,  and  commencement  of  carious  ulceration.  At  this 
date  there  was  but  slight  physical  evidence  of  lung  disease. 

Fig.  73. — Characteristic  ulceration  of  larynx,  especially  of  epiglottis  (on 
left  side  of  which  there  is  also  seen  a  small  false  mucous  growth),  occurring 
in  a  male  patient,  ast.  44,  with  ir.oist  cavities  in  both  apices.    (Page  404.) 

Fig.  74. — Thickening  of  epiglottis  and  arytenoid  cartilages  in  a  male 
patient,  the  subject  of  laryngeal  phthisis,  aet.  36,  who  had  suffered  pain  in 
swallowing  for  eight  months ;  pain  in  the  chest,  cough,  and  hoarseness  for 
four  months.    Disease  at  left  apex.    (Page  403.) 

Fig.  75. — Advanced  stage  (three  months  later)  of  case  shown  in  Fig.  72. 
Patient,  a  lithographer,  aet.  37,  had  now  well-marked  evidence  of  a  cavity 
at  right  apex.  The  right  vocal  cord  is  seen  paralyzed  ;  breathing  was 
stridulous,  and  paroxysms  of  dyspnoeal  cough  frequent.    (Page  404.) 

Fig.  76. — Appearance  of  larynx  in  a  patient  the  subject  of  laryngeal 
syphilis,  and  under  observation  for  over  three  years,  in  which  phthisis 
developed  in  the  left  lung. 

Fig.  77. — Primary  perichondritis  of  the  left  plate  of  the  cricoid  cartilage 
leading  to  the  formation  of  an  encysted  abscess,  which  rose  as  high  as  the 
summit  of  the  arytenoid  cartilage.  The  drawing  was  made  from  a  lady, 
aet.  65,  a  patient  of  Dr.  Mackenzie's,  by  the  author,  who  had  sole  charge  of 
her  during  the  last  five  or  six  weeks  of  her  life.  The  case,  which  is  one  of 
great  interest,  is  fully  reported  by  Dr.  Mackenzie  in  the  '  Transactions  of 
the  Pathological  Society,'  vol.  xxi.    (Page  317.) 

Fig.  78. — Degeneration  (believed  to  be  due  to  gouty  or  calcareous 
deposit)  of  the  epiglottis,  with  symptoms  of  enlargement  of  the  right  crico- 
arytenoid articulation.  The  case  was  that  of  a  gentleman,  £et.  62,  of 
confirmed  gouty  habit.    (Page  313.) 

Fig.  79. — Perichondritis  at  the  right  crico-arytenoid  articulation,  with 
formation  of  infra-glottic  abscess  and  paralysis  of  right  vocal  cord,  occurring 
in  a  maiden  lady,  aet.  62,  with  evidence  of  gouty  inflammations  in  other 
regions  of  the  body.    (Page  31 70 


PLATK  VJII 


712 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  IX. 

Benign  AND  Malignant  Growths  of  the  Larynx. 

(Chapters  XXI.  and  XXI I, ,  pages  447  to  498.) 

Fig.  80. — Fibro-cellular  polypus  situated  beneath  the  vocal  cords,  with  some  general 
congestion  of  the  larynx.  The  growth  was  removed  by  means  of  Gibb's  snare,  December  5, 
1876,  from  E.  A.,  set.  22,  married,  without  children,  and  engaged  as  an  artificial  flower- 
maker.  After  the  operation  she  regained  her  voice,  which  had  been  quite  lost  for  six 
months.    There  was  a  history  of  syphilis  in  this  case. 

Fig.  81. — Papilloma  situated  in  the  inter-arytenoid  fold,  above  the  level  of  the  vocal 
cords,  and  not  therefore  interfering,  except  quite  occasionally,  with  the  voice.  The 
drawing  was  taken  from  a  patient,  ast.  26,  an  actor,  who  had  contracted  syphilis  four 
years  previously,  and  who  suffered  from  irritable  cough,  but  pursued,  and  still  pursues,  his 
vocation. 

Fig.  82. — Papilloma  on  the  left  vocal  cord,  interfering  greatly  with  the  voice,  which 
varied  from  hoarseness  to  complete  aphonia.  This  growth  was  removed  by  Jellenfy's 
instrument  from  a  male  patient,  a  hawker,  set.  32. 

Fig.  83. — Mucous  polypus  attached  by  very  fine  pedicle  to  the  right  vocal  cord  of  a 
bass  singer,  set.  30,  the  patient  of  Dr.  Llewelyn  Thomas,  who  kindly  sent  him  to  the 
author  for  inspection.  The  peculiarity  of  this  case  was  that  the  growth  did  not  in  the 
least  interfere  with  the  singing  voice,  and  the  patient  was  engaged  twice  daily  in  choir 
work.  In  ex-spiration  the  growth  rested  on  the  superior  surface  of  the  vocal  cord  (a),  and 
in  deep  inspiration  could  be  drawn  quite  beneath  it  and  out  of  sight.  With  quick  respi- 
ratory movements  the  polypus  could  be  seen  to  flap  to  and  fro  {d).  Dr.  Thomas  success- 
fully dislodged  it  by  friction  with  a  laryngeal  brush. 

Fig.  84. — Symmetrical  papillomata  in  the  case  of  Mr.  T.  F.,  with  syphilitic  history. 
(Page  456.) 

Fig.  85. — Papillomata  growing  from  left  ventricle  and  from  under  surface  of  right  vocal 
cord,  with  mucous  polypi  on  under  surface  of  epiglottis  and  on  left  ventricular  band.  The 
majority  of  the  growths  were  removed  by  tube-forceps,  and  a  great  improvement  resulted, 
when  the  patient,  a  man,  set.  38,  who  had  already  visited  other  hospitals,  ceased 
attendance. 

Fig.  86. — Fibroma  on  left  vocal  cord  causing  hoarseness  in  a  female  patient,  a  hawker, 
set.  38.  Applications  of  astringents  (principally  iron)  were  of  service  in  this  case,  but 
operative  treatment  was  declined. 

Fig.  87. — This  drawing  is  a  re])lica  of  one  figured  by  the  author  in  Mackenzie's  work 
on  growths  in  the  larynx,  and  is  there  described  as  an  adenoma.  The  growth,  which  was 
removed  by  Dr.  Mackenzie,  'was  exhibited  by  him  at  the  Pathological  Society  ("  Trans- 
actions," vol.  xxi.),  and  referred  for  investigation  to  the  Morbid  Growth  Committee.  The 
Sub-Committee  appointed  to  examine  the  specimen  considered  it  a  case  of  "adenoid 
carcinoma ;"  but  the  report  was  not  confirmed  by  the  full  committee,  and  does  not  appear 
in  the  "Transactions."'  It  is,  however,  interesting  to  add  that  the  patient,  in  whose 
case  there  was  also  distinct  syphilitic  history,  died  of  malignant  ulceration  of  the  larynx, 
commencing  at  the  seat  of  the  tumour.  The  case  is  here  inserted,  as  it  well  serves  to 
illustrate  the  author's  fifth  proposition  at  page  457. 

Fig.  88. — Pharyngo-laryngeal  epithelioma  commencing  at  the  glosso-epiglottic  and 
pharyngo-epiglottic  fold,  and  thence  invading  the  larynx.  Necrosis  of  the  cartilages  has 
already  commenced.    Male  patient,  set.  58.    (Page  482.) 

Fig.  89. — The  same  disease,  distorting  the  epiglottis  and  pushing  the  larynx  out  of  the 
median  line.    Male  patient,  set.  63. 

Fig.  90. — The  same  disease  commencing  in  the  hyoid  fossa.  The  left  vocal  cord  is 
seen  to  be  paralyzed.    Male  patient,  set.  60. 

Fig.  91. — Lympho-sarcoma  of  the  larynx,  occurring  in  a  female  patient,  cet.  47.  The 
disease  had  been  diagnosed  by  another  practitioner  six  months  previously.  This  drawing 
was  made  in  March,  1877,  very  shortly  before  death.  The  case  is  described  at  page  485. 
and  the  post-mortem  appearance  is  depicted  as  Fig.  120  on  Plate  XIV. 


PLATE  IX 


Eig.  80. 


cu 


u 


Pig.  83 


I^ig.  81. 


Fig.  84- 


Fig.  82. 


Fig.  85 


Fig.  86. 


Fig.  87 


Fig.  90 


Fig.  91 


714 


DISEASES  OE  THE 


THROAl'  AND  NOSE. 


PLATE  X. 

Neuroses  of  the  Larynx. 

Fig.  92.  —  Appearance  of  normal  larynx  after  death,  showing  the 
'  cadaveric '  position  of  the  vocal  cords  ;  this  is  also  their  position  during 
quiet  respiration.    (Page  508.) 

Fig.  93. — Bilateral  paralysis  of  adductors  (crico-arytenoidei  laterales  and 
arytenoideus).    Appearance  in  attempted  phonation.    (Page  508.) 

Fig.  94. — Unilateral  paralysis  of  adductors  of  left  cord.  Appearance  in 
attempted  phonation.    (Page  510.) 

Fig.  95. — Bilateral  paralysis  of  abductors  (crico-arytenoidei  postici). 
Appearance  with  deep  inspiratory  effort.    (Page  511.) 

Fig.  96. — Unilateral  paralysis  of  left  abductor.  Appearance  in  deep 
inspiration.  The  affected  cord  is  seen  to  be  in  the  cadaveric  position. 
(Page  513.) 

Fig.  97. — The  same  condition.  Appearance  in  phonation  ;  the  right 
cord  is  seen  to  come  beyond  the  median  line,  while  the  left  is  found  in  the 
cadaveric  position.    (Page  515.) 

Fig.  98. — Bilateral  paralysis  of  the  sphincter  of  the  glottis  (thyro  aryte- 
noidei).    (Page  516.) 

Fig.  99.— Bilateral  paralysis  of  the  arytenoideus.    (Page  517.) 

Fig.  100. — Bilateral  paralysis  of  the  thyro-arytenoidei,  and  of  the  aryte- 
noideus.   (Page  517.) 


PLATE  X 


Hansard  PuHLisKixg  Unton  L" 


7i6  DISEASES  OF  THE  THROAT  AND  NOSE. 


PL  ATE  XT. 

TUBETRCULOSIS  OF  LaRYNX  AND  TONGUE. 

Fig.  loi. — Laryngoscopic  appearance,  details  of  which  are  given  at 
page  409. 

Fig.  102. — Tuberculous  ulcer  of  tongue  during  life,  details  of  which  are 
also  given  at  page  409. 

Fig.  103. — Tuberculous  ulcer  of  tongue  of  the  same  case  after  death. 

Figs.  104  and  105. — Post-mortem  appearance  of  the  larynx  of  the  same 
patient,  detailed  description  of  which  is  given  at  page  409. 


PLATE  XI 


DISEASES  OF  THE  THROAT  AND  NOSE 


PLATE  XII. 

Laryngeal  Tuberculosis. 

Figs.  1 06  and  107. — Laryngoscopic  appearances  at  various  stages  of  a 
case  of  tubercular  laryngitis,  the  details  of  which  are  given  at  page  407. 

Fig.  108. — Post-mortem  appeaiance  of  the  same  case,  the  details  of  which 
are  also  given  at  page  407. 


PLATE  yA 


Fiq  .108. 


720 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  XIIT. 

Fig.  109. — Tertiary  syphilis  of  hard  and  soft  palate.  (Case  related  at 
page  205.) 

Fig.  1 10. — Multiple  ulceration  in  tertiary  syphilis  of  pharynx.   (Page  205.) 

Fig.  1 1 1. — Pharyngitis  sicca.  (Pages  197  and  640.)  Compare  with  Fig  37, 
Plate  V. 

Fig.  112. — Epithelioma  of  soft  palate.    (Described  at  page  265.) 

Fig.  113. — Syphilitic  ulceration  of  the  velum  and  pharynx  in  a  scrofulous 
patient.    (Case  described  at  page  213.    See  also  page  435-) 

Fig.  1 14. — Primary  epithelioma  of  tonsil.    (Case  described  at  page  265.) 


PI, ATI'  XJII 


722 


DISEASES  OF  THE  THROAT  AND  NOSE. 


PLATE  XIV. 

Fig.  T15. — Traumatic  membranous  inflammation  and  haemorrhagic  extra- 
vasation of  the  uvula.  Case  was  that  of  C.  B.,  aet.  46,  a  carpenter,  who 
apphed  at  the  hospital,  February  3,  1879,  stating  that  he  had  experienced 
pain  in  swallowing  a  piece  of  crust  of  bread  at  dinner  the  previous  day, 
and  found  the  rest  of  the  meal  painful.  Was  not  in  very  good  health  at  the 
time,  and  had  had  shiverings  two  or  three  days  previously.  The  trouble 
subsided  under  salicylates,  and  the  sucking  of  ice  in  small  pieces.  (Page 
231) 

Fig.  116. — Inflammation  and  slough  on  uvula,  seen  in  a  patient,  KateG., 
aged  19,  on  the  same  day  as  the  last  case.  Had  experienced  pain  in  eating 
some  pie  four  days  previously,  and  had  had  pain  ever  since.  The  case  was 
treated  by  similar  measures.    (Page  231.) 

Fig.  117. — Post-mortem  appearance  of  diphtheria,  showing  the  variation 
in  the  colour  of  membrane  in  various  situations.  That  on  the  tonsils  and 
palate  being  the  earliest  deposited,  is  seen  to  be  the  darker  and  firmer, 
while  that  low  down  in  the  trachea  has  the  '  hoar-frost '  appearance  of  the 
membrane  when  first  exuded.    (Page  346.) 

Fig.  118. — Chorditis  hcCmorrhagica,  seen  in  a  young  girl  suffering  from 
aphonia,  on  February  3,  1879,  who  had  been  a  patient  for  a  fortnight 
previously.    (Page  273.) 

Fig.  119. — Stenosis  of  the  larynx,  after  lupus.  (Case  described  at  length, 
page  429. 

Fig.  120. — Post-mortem  appearance  of  lympho-sarcoma  of  the  larynx,  as 
described  at  page  485.    See  also  Fig.  91,  Plate  IX. 

Fig.  121. — Internal  aspect  of  half  of  the  larynx,  removed  during  life  fcr 
epithelioma.    (Case  described  at  page  495  seq.) 


PLATE  XiV. 


724 


DISEASES  OF  THE  THROAT  AND  NOSE, 


PLATE  XV. 

Lymphatic  Vessels  of  the  Base  of  the  Tongue,  Tonsils,  Larynx, 
AND  Pharynx.    (Pages  466  to  474.) 

(Reduced  from  Sappefs  ^  Atlas  of  the  Lymphatic  System.^) 

i'\  PoLterior  portion  of  lymphatic  network  of  dorsum  of  tongue.  2".  Cir- 
cum vallate  papillae  of  the  tongue.  3"",  4",  5",  6",  7",  8".  Lymphatic  vessels 
from  the  tongue,  pillars  of  the  fauces,  etc.,  all  converging  towards  the  group 
of  glands  (13")  w^iich  are  situated  under  the  thyro-hyoid  ligament,  between 
the  inferior  cornu  of  the  hyoid  bone  (20")  and  the  superior  cornu  of  the 
thyroid  cartilage  (21").  9".  Tonsils.  10"".  Velum  palati  and  uvula  laid 
open  from  behind.  11".  Epiglottis.  12".  Lymphatic  vessels  of  the 
pharyngeal  aspect  of  the  larynx.  14".  Lymphatics  of  the  lower  two-thirds 
of  the  pharynx.  15".  Lymphatics  of  the  posterior  pillar  of  the  fauces. 
16".  Lymphatics  of  the  posterior  and  middle  wall  of  the  pharynx. 
i^'-  Small  and  numerous  lymphatics  of  the  anterior  or  laryngeal  wall  of 
the  pharynx.  18".  Lymphatics  of  the  posterior  and  lower  portion  of  the 
walls  of  the  pharynx.  These  empty  themselves  into  the  glands  situated  to 
the  right  and  left  of  the  conical  portion  of  the  oesophagus.  19".  Lymphatics 
of  the  anterior  and  lower  portion  of  the  walls  of  the  pharynx  having  the 
same  destination.  22".  Posterior  boundaries  of  the  thyroid  cartilage,  as 
seen  under  the  mucous  membrane  of  the  pharynx. 


PLATE  XV. 


Fig.  122. 

LYMPHATIC  VESSELS 
OF  THE  BASE  OF  THE  TONGUE,  TONSILS,  LARYNX  AND  PHARYNX. 

(Reduced  from  SAPPEY'S  Atlas  of  the  LympJiAtU  System). 


GENERAL  INDEX. 


For  references  to  authors,  see  bibliographical  lists  at  the  end  of  each  chapter. 


A 

Abductor  of  larynx,  unilateral  paralysis  of 

(Figs.  96  and  97,  Plate  X.),  513. 
Abductors  of  larynx,  bilateral  paralysis  of 

(Fig.  95,  Plate  X.),  511. 
Abductors  of  larynx,  proclivity  of,  to  paralysis, 

513- 

Abscess  of  larnyx,  317. 

,,      post-pharyngeal,  187. 

,,      retro-pharyngeal,  187. 
tonsillar,  241. 
Abscission  of  uvula,  235. 

Abuse  of  stimulants  as  cause  of  cancer  ol 

larynx,  478. 
Abuse  of  stimulants  as  cause  of  chronic 

laryngitis,  290. 
Abuse  of  stimulants  as   cause   of  chronic 

pharyngitis,  191. 
Abuse  of  tobacco  as  cause  of  cancer  of  larvnx, 

478. 

Abuse  of  tobacco  as  cause  of  chronic  laryn- 
gitis, T74,  290. 

Abuse  of  tobacco  as  cause  of  chronic  pharyn- 
gitis, 174,  191. 

Abuse  of  voice  as  cause  of  acute  laryngitis. 
278. 

Abuse  of  voice  as  cause  of  benign  laryngeal 

neoplasms,  448. 
Abuse  of  voice  as  cause  of  chronic  laryngitis. 

171,  289. 

Abuse  of  voice  as  cause  of  chronic  pharyn- 
gitis, 192. 

Abuse  of  voice  as  cause  of  malignant  laryn- 
geal neoplasms,  478. 

Accessory  cavities  of  nose,  diseases  of,  551, 
626. 

Accessory  cavities  of  nose,  new  growths  of, 
627, 

Acoumeter,  652. 
Acute  coryza,  557. 

,,    inflammation  of  uvula,  231. 

,,  laryngitis  (Figs.  44,45,  46,  Plate  VI.), 
277. 

Acute  laryngitis,  diagnosis  of,  286. 

,,       treatment  of,  287. 
nasal  catarrh,  557. 
,,    oedema  of  larynx,  300. 

,,  tracheotomy  in,  308. 

,.    pharyngitis  (Fig.  12,  Plate  11. ),  179. 
,,    rhinitis,  557. 

,,  submucous  inflammation  of  larynx 
(oedema),  300. 


Acute  tonsillitis  (Fig.  31,  Plate  IV. ;  and  Fig. 

36,  Plate  v.),  241. 
Adductors  of  larynx,  bilateral  paralysis  of 

(Fig.  93,  Plate  X.),  508. 
Adductors  of  larynx,  spasm  of,  518. 
Adductors  of  larynx,  unilateral  paralvsis  of 

(Fig.  94,  Plate  X.),  510. 
Adenoid  growth  of  naso-pharynx,  522,  552, 

637,  670. 

Affections,  spasmodic,  of  larynx,  517 
Albuminuria  in  diphtheria,  344,  355. 

,,  in  tonsillitis,  247. 

Ammonium  chloride,  inhalation  of,  108. 
Amygdalitis,  241. 
Ancesthesia  of  larynx,  500. 

,,  pharynx,  222. 

Anatomy  of  Eustachian  tube,  37,  668. 
,,         larynx,  6. 
nose,  33. 
oesophagus,  32. 
,,        palate,  26. 
,,         pharynx,  28. 
,,         tonsils,  28,  239. 
,,         uvula,  27. 
,,         vocal  cords,  15. 
Angeioma  of  larynx,  454. 
Angina  laryngis  simplex  vel  catarrhalis,  277. 
Angina  tonsillaris,  241. 
Anosmia  or  Anosphresia,  534,  624. 
Anterior  nasal  douche,  120. 
, ,      rhinoscopic  image,  79. 
rhinoscopy,  76. 
sesamoid  cartilages,  13. 
Antrum  of  Highmore,  catarrh  of,  626. 

,,       empyema  of,  551,  626. 
Aphagia  as  a  symptom,  94. 
Applications,  external,  to  throat,  116,  685. 

internal,  to  throat,  124,  685. 
Aprosexia  in  nasal  stenosis,  547. 
Arteries  of  larynx,  21.^ 

Articulation,   defects  of,   as   symptoms  of 

throat  diseases,  89,  91. 
Artificial  feeding  in  throat  diseases,  148. 
Ary-epiglottic  folds,  20. 

muscles,  paralysis  of,  505. 
Arytenoid  cartilages,  10. 
Arytenoideus,  muscle,  19. 

,,      paralysis  of,  508,  517. 
proprius,  paralysis  of  (Fig.  99, 
Plate  X.),  517. 
Asynergy  of  vocal  cords,  51. 
Atmosphere  in  relation  to  throat  diseases,  173. 


726 


GENERAL  INDEX. 


Atomized  fluids,  inhalations  of,  109. 
Atrophic  rhinitis,  characteristics  of,  543,  579, 
672. 

Atrophy,  nasal,  554. 

,,       of  tonsils,  259. 
Aural  case,  how  to  examine,  652. 
case  paper,  662,  667. 
diseases,  diagnostic  table  of,  656. 
,,         ,,       physical  and  objective  signs, 
657- 

Aural  granulations,  676. 

,,    maladies  associated  with  naso-pharyn- 

geal  disease,  650. 
Aural  maladies,  general  etiology  of,  665. 

,,  ,,  ,,      therapeutics  of,  682. 

treatment    of,   by  vapours, 

106,  675. 
Aural  exostoses,  676. 
polypi,  676. 

,,    vertigo,  654. 
Aurium,  tinnitus,  653,  674. 
Auto-laryngoscopy,  72. 

B 

Balneo-therapeutics,  152. 

Bands,  ventricular,   of  larynx  (false  vocal 

cords),  15,  66. 
Baths,  Turkish,  107. 
Benign  growths  on  tonsils,  260. 
,,     neoplasms  of  larynx,  447. 
,,  ,,  etiology  of,  448. 

,,  ,,  ,,     pathology  of, 

452. 

Benign  neoplasms  of  larynx,  symptoms  of, 
453- 

Benign  neoplasms  of  larynx,  thyrotomy  for, 
464. 

Benign  neoplasms  of  larynx,  tracheotomy  in, 
465- 

Benign  neoplasms  of  larynx,  treatment  of, 
455.  459- 

Benign  neoplasms  of  larynx,  varieties  of,  454. 
Bifurcated  uvula,  237, 
Blenorrhoea,  chronic,  298. 
Bones  and  bodies  turbinated,  86. 

„     atrophy  of,  543,  579. 

,,    hypertrophy  of,  541,  542,  571. 

,,    nasal,  necrosis  of,  609. 
Brush,  cotton-wool,  125. 

,,     laryngeal,  126. 
Buccal  lining,  examination  of,  58. 

,,     mycosis,  260. 
Bursa,  Luschka's,  catarrh  of,  552,  636. 
Bursitis,  naso-pharyngeal,  552,  636. 

C 

Calcareous  concretion  of  tonsils,  260. 
Carcinoma  of  larynx,  467. 
,,  pharynx,  229, 

,,  tonsils,  261. 

Cartilage,  arytenoid,  10. 
,,       cricoid,  8. 
,,       epiglottis,  13,  64. 
,,       inter-arytenoid,  13. 

of  larynx,  6. 
,,       of  larynx,  anterior  sesamoid,  13. 
,,       posterior-sesamoid,  13. 
,,       thyroid,  7. 
Cartilages  of  larynx,  fibroid  degeneration  of, 
^  312. 

Cartilages  of  larynx,  inflammation  of,  311. 
,,  ,,      strumous    diseases  of, 

312. 

Cartilages  of  Santorini,  11,  66. 


Cartilages  of  Wrisberg,  12,  66. 
Catarrh,  acute  nasal,  557. 

,,       chronic  laryngeal,  289. 

,,       chronic  non-suppurative,  of  ear,  672. 

,,       of  antrum  of  Highmore,  551,  626. 

,,       of  ethmoidal  and  frontal  sinuses, 

551.  633- 
Catarrh,  of  sphenoidal,  551,  634. 
,,       post-nasal,  635. 
,,       summer  (see  Nay  Fever),  544,  565. 
suppurative,  of  middle  ear,  676. 
Caustic-holder,  laryngeal,  129. 
Caustics  in  cancer,  490. 

,,       in  laryngitis,  296, 
Cautery,  galvano,  135. 

,,       see  Galvaiio-Caiitej'y. 
Cavities,  accessory,  of  nose,  disease  of,  551,  626. 
Chicken-pox,  laryngitis  in  (Fig.  51,  Plate  VI.), 
280. 

Chicken-pox,  pharyngitis  in  (Fig.  16,  Plate 

II.),  190. 
Children,  laryngoscopy  in,  53. 
Chondro-sarcoma  of  larynx,  316. 
Chorditis  haemorrhagica,  273. 

,,       inferior  hypertrophica,  298. 
,,       tuberosa,  291. 
Chorea  of  larnyx,  518. 
Chronic  atrophic  rhinitis,  541,  579. 
,,       blenorrhoea,  298. 
,,       catarrh  of  larynx,  289. 
,,       hypertrophic  rhinitis,  543,  571,  670. 

inflammation  of  larynx,  289. 
,,  ,,         of  pharynx,  191. 

,,  ,,         of  tonsils,  252. 

,,  ,,         of  uvula,  232. 

,,       laryngitis,  289. 

nasal  diseases,  classification  of,  55^* 
,,  non-suppurative  catarrh  of  ear,  672. 
,,       pharyngitis,  191. 

,,  lateralis  hypertrophica, 

193- 

Chronic  relaxed  throat,  232. 

,,  sub-glottic  inflammation  of  larynx, 
298. 

Classification  of  neuroses  of  larynx  (Gott- 
stein),  504. 

Classification  of  neuroses  of  larynx  (Lefferts), 
504- 

Classification  of  neuroses  of  larynx  (Morell- 

Mackenzie),  505. 
Classification  of  neuroses   of  larynx  (Solis 

Cohen),  505. 
Classification  of  neuroses  of  larynx  (Von 

Ziemssen),  504. 
Cleavage,  nasal,  611. 
Clergyman's  sore  throat,  191, 
Climate  in  relation  to  throat  diseases,  173. 
Clothing  in  relation  to  throat  diseases,  175. 
Coarse  nasal  spray,  122. 
'  Cold-catching,'  164. 

,,    inhalations,  108. 
Collunaria,  119,  687. 
Colour,  as  a  symptom,  96. 
Commemorate  symptoms  of  throat  diseases, 

88,  97. 

Compressed  air,  inhalations  of,  109. 
Congenital  syphilis  of  larynx,  396. 
,,  ,,         pharynx,  209. 

!  Constrictors  of  larynx,  paralysis  of,  516. 

,,  pharnyx,  31. 

j  Consumption  of  throat,  213,  399. 
Conversation-test  of  hearing,  651. 
Cords,  vocal,  15,  66. 
Coryza,  acute,  557. 

,,      specific,  562. 
Cotton-wool  brush,  125,  126. 


GENERAL  INDEX. 


727 


Cough,  as  a  symptom,  92. 
laryngeal,  93. 
,,     nervous  laryngeal,  521. 
Crico-arytenoid  articulation,   anchylosis  of, 
315. 

Crico-arytenoidei  laterales,  bilateral  paralysis 
of,  518. 

Crico-arytenoidei  postici,  bilateral  paralysis 
of,  511. 

Crico-arytenoideus  lateralis  muscle,  19. 

,,  posticus  muscle,  18. 

,,    thyroid  muscle,  20. 
Cricoid  cartilage,  8. 
Croup,  321. 

,,     false,  519. 

fibrinous,  323. 
,,     mucous,  323. 

spurious,  323. 
,,     tracheotomy  in,  332. 
,,     traumatic,  333. 
Croupous  laryngitis,  321. 

,,       rhinitis,  563. 
Curettes,  naso-pharyngeal,  646. 

D 

Deformities  of  pharynx,  227. 

Degeneration  of  laryngeal  cartilages  (Figs. 

77,  78,  and  79,  Plate  VIIL),  311. 
Deglutition,  as  a  symptom,  89,  93. 
Deglutitory  therapeutics,  148. 
Deviation  of  septum  nasi,  592. 
Diagnostic  table  of  aural  diseases,  656. 
Diathesis  in  tonsillitis,  243. 
Dietetic  therapeutics  of  throat  diseases,  148. 
Differential  diagnosis  of  cancer  of  tonsil,  267. 

croup,  328. 
diphtheria,  352. 
,,  ,,  laryngeal  syphilis, 

382,  385- 

Differential  diagnosis  of  laryngeal  tubercu- 
losis, 414. 

Differential  diagnosis  of  laryngitis,  286. 

pharyngeal  syphilis, 

218. 

Differential  diagnosis  of  pharyngeal  tubercu- 
losis, 218. 

Differential  diagnosis  of  tonsillitis,  248. 
Digital  examination  of  nares,  84. 
Dilatation  of  the  pharynx,  227. 
Diphtheria,  age,  in  relation  to,  341. 
,,         complications  of,  352. 
,,         constitution,  in  relation  to,  341. 
,,         contagium  of,  335. 
,,        dietary  of,  367. 
,,         differential  diagnosis,  352. 

digestive  tract  of,  343. 
,,         dissemination  of,  338. 

etiology  of,  335. 

germ  theory  of,  336. 

heart,  344, 
,,         histology  of,  344. 

hygiene  of,  377. 
,,         incubation  of,  341. 

inoculability  of,  338. 

intubation  in,  371. 

kidneys,  344. 

lungs,  344. 
, ,        mode  of  origin  of,  338. 
,,        pathology  of,  343. 
,,         prophylaxis  of,  377. 
,,,        ptomaine  theory  of,  337. 
,,         recurrence,  356. 
,,         season,  in  relation  to,  340. 

sequelae  of,  352. 
.,,        spleen,  344. 


Diphtheria,  sporadic,  339. 

,,        symptoms  of,  functional,  347. 

physical,  349. 
tracheotomy  in,  369. 
treatment  by  caustics,  363. 
,,         by  diaphoretics,  358. 
,,         by  emetics,  357. 
,,  ,,         by  expectorants,  358. 

,,  ,,         by  germicides,  359. 

'    ,,         by  solvents,  361. 
,,  ,,         by  specifics,  358. 

by  steam,  365. 
,,  ,,         by  varnishes,  365. 

external,  366. 
general,  357. 
internal,  357. 
local,  361. 
of,  356. 

,,  ,,         operative,  368. 

varieties  of,  351. 
Diphtheritic  paralysis,  352,  505,  671. 
Directions  for  inhaling,  105. 
Discharge  from-the  ears,  652,  676. 
Disease,  naso-pharyngeal,  in  connection  with 

aural  maladies,  650,  665. 
Disease,  Tornwaldt's,  552,  636,  671. 
Diseases,  nasal,  classification  of,  556. 

, ,  diagnosis  and  treatment  of,  556. 

,,  general    etiology    and  path- 

ology of,  532. 
Diseases  of  ethmoidal  sinuses,  551,  588,  632. 
of  frontal  sinus,  551,  633. 
of  larynx,  classification  of,  275. 
of  olfactory  region,  534,  624. 
of  pharynx,  176. 

of  respiratory  region  of  nose,  535. 

of  sphenoidal  sinus,  551,  634. 

of  throat,  etiology  of,  154. 

of  tonsils,  239. 

of  uvula,  231. 
Douches,  anterior,  119. 
,,       nasal,  119. 
,,        posterior,  121. 
Dry  inhalations,  104. 
Dust  in  relation  to  throat  diseases,  174. 
Dysphagia,  as  a  symptom,  93. 

E 

Ear,  chronic  non-suppurative  catarrh  of,  672. 

,,    disease,  eye  affections  in  relation  to,  661. 

,,    disease,  new  growths  in,  661. 

,,    diseases  of,  650,  665. 

,,    diseases  of,  associated  with  naso-pharyn- 
geal affections,  650,  665. 
Ear,  diseases  of,  functional  and  subjective 

symptoms  of,  651. 
Ear,  examination  of,  650. 

, ,    noises  in,  653. 

,,    pain  in,  in  cancer  of  larynx,  482. 

,,         ,,  ,,         tonsil,  266. 

,,  tonsillitis,  246. 

,,    suppurative  catarrh  of,  676. 
Ears,  discharge  from,  652,  676. 

,,  pain  in,  653. 
Eczema  auris,  686. 

Eggs,  raw,  in  obstructed  deglutition,  148. 

Electric  laryngoscope,  44. 

Electrodes,  laryngeal,  134. 

Elongated  uvula  (Figs.  13  and  14,  Plate  II.  ; 

and  Figs.  29  and  32,  Plate  IV.),  232. 
Empyema  of  maxillary  antrum,  551,  626. 
Encephaloid  cancer  of  larynx,  468. 

,,  ,,      of  tonsils,  262. 

Enchondromata,  nasal,  620. 
Endo-laryngeal  cauterization,  296,  490. 


728 


GENERAL  INDEX. 


Enlarged  tonsils  (Figs.  32  and  33,  Plate  IV.), 
252. 

Enlarged  tonsils,  removal  of,  256. 
Enlargement  of  palate,  causing  deafness,  671. 

,,  of  tonsils,  ,,  671. 

Epiglottis,  anatomy  of,  13,  64. 
,,        colour  of,  65. 
,,        functions  of,  14. 
, ,        ligaments  of,  65. 

movements  of,  14,  65. 

variations  in  form  of  (Plate  I.), 

65- 

Epilepsy,  laryngeal.  523. 
Epileptiform  neuroses  of  larynx,  523. 

,,  ,,       of  nose,  545. 

Epitaxis,  622. 

Epithelioma  of  larynx,  468. 

,,  of  tonsils,  264. 
Erectile  tissue  of  nose,  536. 
Erysipelatous  laryngitis,  301,  303. 

,,  pharyngitis,  184. 

Ethmoidal  sinuses,  disease  of,  551.  633. 
Ethmoiditis,  necrosing,  609. 
Etiology  of  nasal  diseases,  532. 

,,        of  throat  diseases,  154. 
Eustachian  catheter,  employment  of,  674. 
cushion,  87. 

tube,  anatomy  of,  35,  668. 
,,  examination  of,  660. 
,,  obstruction  of,  668. 
,,     Politzer  inflation  of,  660, 

672. 

Eustachian  tube,  Valsalvan  inflation  of,  660, 
672. 

Examination,  laryngoscopic,  48. 

of  mastoid  process,  660. 
,,  of  membrana  tympani,  657. 

,,  of  tympanic  cavity,  66o. 

,,  ophthalmoscopic,  98. 

,,  sphygmographic,  98. 

stethoscopic,  98. 
Exostoses,  nasal,  620. 
External  applications  to  formulae  for,  685. 

,,     throat,  116. 

,,       otitis,  676. 
Extirpation  of  larynx,  complete,  492. 

I.  5)         partial,  493. 

Eye  affections  in  relation  to  ear  disease,  661. 
,,   disease,  due  to  nasal  reflex,  548. 

p 

False  croup,  519. 
Faradism  of  larynx,  134. 
Fauces,  examination  of,  53. 
,,      inflanmiation  of,  178. 

lepra  of,  222,  443. 

lupus  of,  222,  427. 

neuroses  of,  222. 

syphilitic  ulceration  of,  201. 
,,      tubercular  ulceration  of,  213. 
Feeding,  artificial,  148. 
Fever,  Hay,  545,  565. 
Fibrinous  croup,  321. 
Fibro-cellular  growth  of  larynx,  452. 
Fibroid  degeneration  of  laryngeal  cartilages, 
311- 

Fibromata,  nasal,  618. 

naso-pharyngeal,  649. 
Fibromatous  growths  of  larynx,  452, 
Foetor  of  breath  as  a  symptom,  89,  94,  579, 

583,  629. 
Follicular  laryngitis,  291. 
,,       pharyngitis,  191. 
,,       tonsillitis,  242,  252. 
Forceps,  laryngeal,  131. 
,,       nasal,  139. 


Foreign  bodies  in  larynx  (Plate  VI.,  Fig.  54), 
i  306. 

Foreign  bodies  in  nose,  625. 
I  ,,  pharynx,  229. 

Form,  alteration  of,  as  a  symptom,  96. 

Fossa,  hyoid  (Plate  I.),  63. 
,,     of  Robenmiiller,  87. 

Frontal  sinus,  catarrh  of,  633. 

Fumigations,  mercurial,  114. 

Fuming  inhalations,  115. 

Functional  symptoms  in  throat  diseases,  88, 
91. 

Functions  ot  nostrils,  538. 

,,        of  tonsils,  156,  240. 

,,        ot  uvula,  27. 
Fungi  in  nose,  625. 


G 

Galvano-caustic  instruments,  137. 
cautery,  135. 
,,  ,,        in  atrophic  rhinitis,  585. 

,,  ,,        in  cancer,  490. 

,,  ,,        in  enlarged  tonsils,  258. 

,,  ,,        in  hay-fever,  570. 

,,  ,,        in  hypertrophicrhinitis,  576. 

,,  ,,        in  lingual  varix,  225,  236, 

530- 

,,  ,,        in  lupus,  440. 

in  nasal  polypi,  617. 
in  naso-pharyngeal  catarrh, 
637- 

,,  ,,        in  post-nasal  catarrh,  637. 

,,  ,,        in  removal  of  uvula,  236. 

scope  of,  137. 

Gargles,  loi. 

,,       formulas  for,  677, 
Gargling,  methods  of,  102. 
Glandules  of  pharynx,  32. 
Glottic  division  of  larynx,  15. 
Glottis,  vel  rima  glottidis,  17. 

,,     spasm  of,  517. 
Gonnorrhoeal  coryza,  562. 
Gouty  perichondritis  of  larynx,  313. 
Granular  laryngitis,  291. 

,,        pharyngitis,  191. 
Granulomata  of  larynx,  407. 
Growths,  adenoid,  552,  637,  670. 

benign,  of  larynx  (Figs.  80  to  87, 
Plate  IX.),  447. 
Growths,  benign,  nasal,  612. 

,,  ,,       naso-pharynx,  649. 

,,  ,,       of  pharynx,  228. 

,,  ,,       of  tonsils,  260. 

,,  >>       of  uvula,  237. 

,,       malignant,  of  larynx  (Figs.  87,  88, 
90,  and  91,  Plate  IX.  ;  and  Figs.  120,  121, 
Plate  XIV.).  467. 
Growth,  malignant,  of  pharynx  (Fig.  112, 

Plate  XIII.),  229, 
Growths,  malignant,  of  nasal,  621. 

,,  ,,         of  naso-pharynx,  649. 

,,  ,,        of  tonsils  (Figs.  34  and 

35,  Plate  IV.  ;  and  Fig.  113,  Plate  XIII.), 
261. 

Growths,  malignant,  of  uvula,  238. 
Gums,  examination  of,  58. 


I  Haemorrhage  after  tonsillotomy,  257. 
,,  ,,    uvulotomy,  236. 

, ,  from  varix,  224,  225. 

,,  in  cancer  of  larynx,  481. 

,,  in  nasal  operations,  598, 


GENERAL  INDEX.  729 


Haemorrhage  in  naso-pharyngeal  operations, 
647. 

,,  in  nasal  polypi,  618. 

,,  ,,     of  tonsils,  268. 

Haemorrhagic  chorditis,  273. 

uvulitis,  230. 
HiEmorrhoids,  lingual,  224. 
Hard  palate,  anatomy  of,  26. 

,,         perforation  of,  206. 
Hay-fever,  544,  565. 

,,       treatment  of,  569. 
Hearing,  as  a  symptom  of  throat  disease,  95. 
,,       power,  testing  of,  651. 
,,      test  of,  by  acoumeter,  652. 
,,      the  watch  as  a  test  of,  652. 
,,      tuning-fork  as  a  test  of,  654. 
Hemi-anaesthesia  of  larynx,  500. 
Hereditary  syphilis  of  larynx,  396. 

,,  of  pharynx,  209. 

Herpes  of  pharynx,  178,182,  191. 
Histology  of  larynx,  270, 
,,       of  tonsils,  239. 
Hospital  sore  throat,  184. 
Hygienic  therapeutics  of  throat  diseases,  147. 
Hyoid  fossa,  (Plate  I.),  63. 
Hyperaemia  of  larynx,  272. 
Hyperaesthesia  of  larynx,  501. 

,,  of  pharynx,  222. 

Hyperplasias  of  nasal  passages,  543,  571, 
670. 

Hypertrophic  rhinitis,  542,  569,  670. 

,,  ,,       varieties  of,  572. 

Hypertrophy  of  Luschka's  tonsil,  536,  552, 
670. 

Hypertrophy  of  pharyngeal  tonsil,  522,  552, 
670. 

I 

Ice  as  a  therapeutic  agent,  103. 
,,  in  diphtheria,  367. 
,,  in  tonsillitis,  251, 
Idiopathic  croup,  321. 
Image,  anterior  rhinoscopic,  79, 
,,      laryngoscopic,  61. 
,,     posterior  rhinoscopic,  85, 
Inflammation,  meningeal,  676. 

,,  of  larynx,  acute  mucous,  278. 

,,  ,,       acute  submucous 

(oedema),  300. 
Inflammation  of  larynx,  chronic  submucous, 
289. 

,,  chronic  submucous, 

308. 

Inflammation  of  larynx,  subacute  mucous,  289. 

, ,  perichondrium  of  larynx, 311. 

Inflammation  of  pharynx,  acute,  179. 

,,         chronic,  191. 
,,  ,,         phlegmonous,  184. 

,,        subacute,  190. 
,,  of  tonsils,  acute  (quinsy),  241. 

,,  ,,       chronic  252. 

,,  of  uvula,  acute,  231. 

,,  ,,      chronic,  232. 

Infra-glottic  division  of  larynx,  16,  67. 

,,        oedema  of  larynx,  304. 
Inhalations,  directions  for,  105. 
,,         dry,  107. 
,,         formulas  for,  680. 
,,         fuming,  114, 

in    obstruction   of  Eustachian 
tube,  106,  675. 
Inhalations,  mercurial,  115. 
nasal,  106. 

of  ammonium  chloride,  108,675. 
,,        of  atomized  fluids,  109. 
,,        of  cold  air,  109. 


Inhalations  of  compressed  air,  109. 

,,  vapour,  104. 

Inhaler,  oro-nasal,  108. 
Injections,  intra-tympanic,  675. 
Inspection  of  ears,  650. 
,,       of  larynx,  48. 
,,       of  mouth,  fauces,  etc.,  55. 
of  nose,  76, 
Insufflations,  127. 

,,         formulas  for,  686. 
Inter-arytenoid  cartilage,  13. 

fold,  thickening  of,  410. 
Intra-tympanic  injections,  675. 
Intubation  in  congenital  syphilis,  397, 
,,         in  tertiary  syphilis,  395. 
,,        of  larynx,  371. 

K 

Kerato-cricoid  muscle,  t8. 

L 

Lactic  acid  in  diphtheria,  364. 

,,        in  laryngeal  phthisis,  423. 

,,        in  lupus,  440. 

,,        in  pharyngeal  phthisis,  221, 
Lacunar  tonsillitis,  242. 
Lancet,  laryngeal,  130. 
Larvae  in  nose,  625. 

Laryngeal  inflammations, classification  of,  275. 
Laryngeal  brush,  125. 

,,       caustic-holder,  128. 
,,       cough,  nervous,  521. 
,,       electrodes,  134. 
,,       forceps,  132. 

image,  47. 
, ,       mirror,  46. 

nerve,  paralysis  of,  in  the  domain 
of  inferior  or  recurrent,  506. 
Laryngeal  nerve,  paralysis  of,  in  the  domain 

of  the  superior,  505. 
Laryngeal  phlebectasis,  293. 
,,        phthisis,  399. 
,,  ,,      diagnosis  of,  414. 

,,      symptoms  of,  409. 
,,      tracheotomy  in,  424. 
,,  ,,      treatment  of,  419. 

reflector,  45. 
,,        snares,  130, 

sponge  probang,  132. 
,,        syringe,  112. 
,,        vertigo,  522. 
Laryngectomy,  complete,  492. 

,,  partial,  493. 

Laryngismus  stridulus,  323,  519,  640. 
Laryngitis,  acute,  277. 
,,        chronic,  289. 
,,        croupous,  321. 

differential  diagnosis  of,  286, 
,,        diphtheritic,  350. 
,,        follicular,  291. 
,,        granulosa,  291. 
,,        in  children,  282, 
,,        in  measles,  282. 
,,        in  scarlatina,  282. 

in  typhoid  fever,  283. 
, ,        in  typhus  fever,  283. 
,,        in  variola,  282, 
,,        nitrate  of  silver  in,  296. 
,,        paralyses  in,  285. 

secondary  syphilitic,  380. 

,,  ,,    symptoms,  382. 

,,  ,,     treatment,  384. 

sicca,  297. 
subacute,  289. 
,,        subglottic,  298. 


730 


GENERAL  INDEX. 


Laryngitis,  submucous,  300, 

,,        syphilitic,  tracheotomy  in,  394. 
,,        tertiary  syphilitic,  384. 
,,  ,.  ,,        symptoms  of, 

385. 

,,  tertiary  syphilitic,  treatment,  390. 
,,        tuberculous,  398. 

tracheotomy  in,  424. 
Laryngoscope,  electric,  44. 
Laryngoscopic  image,  61. 
Laryngoscopy,  cautions  in,  50. 
,,  diffiulties  of,  51. 

,,  in  children,  52. 

,,  principle  of,  47. 

Larynx,  acute  oedema  of,  300. 

,,  ,,  infra-glottic,  304. 

,,  ,,  tracheotomy,  308. 

acute  submucous  inflammation,  300. 
,,      anasmia  of,  271. 
,,      anaesthesia  of,  500. 
,,       anatom.y  of,  6. 
,,      arteries  of,  21. 
,,      as  a  musical  instrument,  25. 
,,      benign  neoplasms  of,  447. 
,,  ,,  symptoms  of,  453. 

,,  ,,  ,,        tracheotomy,  465. 

,,  ,,  ,,        treatment  of,  455. 

,,  „  ,,        varieties,  452,  454, 

,,      carcinoma  of,  467. 
,,      cartilages  of,  6. 
,,       congenital  syphihs  of,  396. 
,,      chondro-sarcoma  of,  316. 

chorea  of,  518. 
,,      chronic    submucous  inflammation, 
298. 

Larynx,  complete  extirpation  of,  492. 
, ,      diseases  of,  270. 
,,      encephaloid  cancer  of,  468. 

epileptiform  neuroses  of,  522. 

epithelioma  of,  468. 
,,      exudative  inflammation  of,  321. 
,,       foreign  bodies  in,  306. 
,,       glottic  division  ot,  15. 
,,       gouty  perichondritis  of,  318. 

haemorrhages  of,  273,  467. 
, ,      hemi-anaesthesia  of,  500. 
, ,      histology  of,  270. 
, ,      hyperaemia  of,  272. 

hyperaesthesia  of,  501. 

inflammations  of,  classification,  275. 

infra-glottic  division  of,  16. 
,,       in  tone  production,  68. 
,,       intubation  of,  371. 
,,      lepra  of,  445. 
, ,      lupus  of,  437. 

,,      lymphatic  system  of,  in  cancer,  468. 
,,      malignant  neoplasms  of,  467. 
,,  ,,  ,,    symptoms,  479. 

,,  ,,  ,,    tracheotomy,  490. 

,,  ,,    treatment,  488. 

,,  ,,  ,,    varieties  of,  468. 

, ,      medullary  cancer  of,  468. 
,,       membranous  inflam.mation  of,  321. 
,,      mucous  membrane  of,  22,  271. 

muscles  of,  17. 
,,       nerves  of,  21. 
, ,      neuralgia  of,  502. 
,,      neuroses  of,  500. 
,,  ,,  motion,  503. 

,,  ,,  sensation,  500. 

,,      parresthesia  of,  502. 

paralysis  of  sphincter  of  (Fig.  98, 
Plate  X.),  si6. 
Larynx,  partial  extirpation  of,  493. 

perichondritis  of,  311. 
,,       pigments  to,  126. 


Larynx,  pigments  to,  formulae  for,  667. 
,,      sarcoma  of,  468. 

scarification  of,  308. 
,,       schirrus  of,  468. 
,,       spasmodic  affections  of,  518. 

supra-glottic  division  of,  14. 
,,      syphilitic  oedema  of,  390. 
,,  ,,       stenosis  of,  388,  391. 

venous  congestion  of,  272. 
Leiter's  coils  to  throat,  117. 
Lepra  of  fauces,  222,  443. 
,,    of  larynx,  445. 
,,    of  nose,  581. 
,,    of  pharynx,  444. 
,,    of  tracheotomy  in,  444. 
Limelight,  the,  42. 
Lingual  varix,  223. 

,,        in  cardiac  weakness,  225. 
,,         in  cerebral  disease,  225. 
,,         in  diabetes,  518. 
,,        in  epileptiform  neuroses,  525. 
Lower  thick  register,  68. 

,,    thin  register,  70. 
Lozenges,  103. 

,,        formulae  for,  678. 
Lupoid  syphilis  of  larynx,  441. 
Lupus  of  fauces,  222,  427. 
,,     of  larynx,  436. 

of  mouth,  222,  427. 
,,     of  nose,  586. 
,,     of  palate,  435. 

of  pharynx,  221,  435. 
,,     of  throat,  diagnosis  of,  438. 

,,       symptoms  of,  434. 

tracheotomy  in,  440. 
,,       treatment  of,  400. 
Luschka's  bursa,  catarrh  of,  517,  634,  671. 
,,       tonsil,  hypertrophy  of,  522,  552, 
637,  670. 
Lympho-sarcoma  of  tonsils,  262. 

M 

Maladies,  aural,  associated  with  naso-pharyn- 

geal  disease,  650,  662. 
Malformations  of  uvula,  237. 
Malignant  neoplasms  of  larynx,  467. 

,,  ,,         pathology  of,  467. 

,,  ,,         symptoms  of,  479. 

treatment  of,  488. 
Massage  of  throat,  141. 
Mastoid  process,  examination  of,  660. 
Measles,  laryngitis  in,  282. 
Meatus  narium,  86. 

Medical  therapeutics  of  throat  diseases,  100. 
Medullary  cancer  of  larynx,  468. 

,,  endo-laryngeal,  489. 
,,  ,,  ,,  extirpation,  493. 

,,  thyrotomy  in.  497. 
,,  ,,  ,,  tracheotomy  in,  490. 

Membrana  tympani,  colour  of,  658. 

cone  of  light  on,  659. 
,,  ,,       curvature  of,  659. 

,,  ,,       examination  of,  657. 

,,  ,,       form  of,  658. 

,,  ,,       inclination  of,  659. 

mobility,    tension,  and 

adhesion  of,  660. 
Membrana  tympani,  surface  entirety  of,  659. 
Membranous  inflammation  of  larynx,  321. 

„  sore  throat,  181. 
Meningeal  inflammation,  676. 
Menthol  in  diphtheria,  366. 

laryngeal  phthisis,  423. 
nasal  disease,  560. 
pharyngeal  phthisis,  222. 


GENERAL  INDEX. 


731 


Mercurial  fumigations,  115. 
Mineral  baths,  152. 
Mirror,  laryngeal,  46. 
Mode  of  origin  of  diphtheria,  339. 
Morgagni,  ventricles  of,  16. 
Motion,  neuroses  of,  of  larynx,  503. 
Motor  paralysis  of  pharynx,  227. 
Mouth,  inspection  of,  55. 

lupus  of,  222,  427. 
,,     tubercular  ulceration  of,  213. 
Mucous  croup,  321, 

membrane,  nasal,  532. 

,,        of  larynx,  22,  271. 
,,        of  naso-pharynx,  87. 
Muscle,  arytenoideus,  19. 
,,     ary-epiglotticus,  20, 

crico-arytenoideus  lateralis,  19. 
crico-arytenoideus  posticus,  18. 
,,     crico-thyroid,  20. 
,,     kerato-cricoid,  18, 
Muscles  of  larynx,  17. 
,,      of  palate,  27. 
of  pharynx,  30. 
Musical  instrument,  larynx  as,  25. 
Mycosis  buccalis  z'^/  tonsillaris,  260. 
Myxomata,  laryngeal,  452, 
nasal,  612. 
,,        naso-pharyngeal,  649. 

N 

Nares,  digital  examination  of,  84. 
Narium  meatus,  86. 

,,      septum,  86. 
Nasal  atrophy,  characteristics  of,  554,  579. 
carcinomata,  621. 
catarrh,  acute,  557. 
,,     cleavage,  611. 
,,     cystomata,  619. 

diseases,  classification  of,  556. 

general  etiology  and  path- 
ology of,  532. 
Nasal  douches,  119. 

,,  ,,       formulae  for,  687. 

,,  ,,       posterior,  i2x. 

enchondromata,  620. 
exostoses,  620. 
,,     fibromata,  618. 
,,     forceps,  139. 
,,     hyperplasias,  543,  571,  670. 
,,     inhalations,  106. 

lepra,  586. 
,,     lupus,  587. 

mucous  membrane,  532. 

myxomata,  612. 

neuroses  epileptiform,  545. 

,,       reflex  in  eye  disease,  548. 
papillomata,  620. 

passages,  hyperplasia  of,  543,  571. 

polypi,  543,  612,  670. 

respiration  as  a  symptom  of,  89,  94. 
,,     sarcomata,  621. 
,,     schirrus,  621. 

sensitive  areas,  567. 

snares,  140. 

sprays,  122. 

stenosis,  objective  signs  of,  553. 

,,       subjective     ,,  554. 
synostosis,  612. 
syringe,  123. 
tampons,  124. 
tuberculosis,  588. 
Naso-pharyngeal  bursitis,  515,  639. 
,,  carcinomata,  608. 

,,  disease  in  connection  with 

aural  maladies,  650,  663. 


Naso-pharyngeal  diseases,  general  etiology 

and  pathology  of,  532. 
Naso-pharyngeal  fibromata,  649. 
,,  sarcomata,  649. 

,,  teratomata,  649. 

,,  tonsil,  32. 

hypertrophy  of,  522, 

552,  637,  670. 
Naso-pharynx,  diseases  of,  635. 

,,  mucous  membrane  of,  87. 

Necrosis  of  nasal  bone,  609. 
Neoplasms,  benign,  of  larynx,  447. 
,,  symptoms  of,  453. 

,,  treatment  of,  455. 

,,  varieties  of,  452,  454. 

Nerves  of  larynx,  21. 
Nervous  laryngeal  cough,  521. 
Neuralgia  of  larynx,  502. 
Neuroses  of  larynx,  500. 

,,        classification    of  (Gott- 

stein),  504. 

Neuroses  of  larynx,  classification  of  (Leffer(s), 
504- 

Neuroses  of  larynx,  classification  of  (Morell- 

Mackenzie),  505. 
Neuroses  of  larynx,  classification  of  (Solis 

Cohen),  505. 
Neuroses  of  larynx,  classification  of  (Von 

Ziemssen),  504. 
Neuroses  of  larynx,  epileptiform,  522. 
,,       of  motion  of  larynx,  503. 
of  nose,  epileptiform,  545. 
reflex,  544,  565. 
,,       of  pharynx,  222. 

of  sensation  in  larynx,  500. 
New  formations  in  pharynx,  227. 

,,   growths  of  uvula,  237. 
Nitrate  of  silver  in  laryngitis,  296. 
Non-suppurative  catarrh  of   ear,  chronic, 
672. 

Nose,  anatomy  and  physiology  of,  33. 
.   ,,     diseases  of  accessory  cavities  of,  551, 
626. 

Nose,  erectile  tissue  of,  536. 

,,     in  voice-production,  540. 
Nostrils,  physiological  functions  of,  538. 

O 

Objective  signs  of  aural  diseases,  657. 

,,  of  throat  diseases,  96. 

Odynphagia,  94. 
Qidema  of  glottis,  287. 

,,        larynx,  acute,  300. 

,,  ,,      syphilitic,  390. 

uvula,  231. 
Oesophageal  Ramoneur,  142. 
CEsophagus,  anatomy  of,  32. 
Olfactory  region,  physiology  of,  532. 
Oro-nasal  inhaler,  108. 
Oro-pharynx,  inspection  of,  55. 
Otitis,  external,  676. 
Otorrhoea,  676. 
Ozaena,  543,  579. 

syphilitic,  579. 

P 

Pain,  as  a  symptom,  96. 
,,    in  cancer  of  larynx,  481. 

,,  tonsil,  266. 

,,    in  the  ear,  482,  653. 

tonsillitis,  251. 
,,        tubercle  of  larynx,  411. 

,,         pharynx,  217. 


732 


GENERAL  INDEX. 


71. 


laryngeal 
bilateral  (Fig.  95, 
93. 


Palate,  enlargement  of,  671, 
examination  of,  58. 
lupus  of,  435. 
perforation  of,  206. 
soft,  in  tone-production, 
the  anatomy  of,  25, 
Papillomata,  nasal,  620, 
Parsesthesia  of  larynx,  502. 

,,         of  pharynx,  223. 
Parageusia,  625. 
Paralyses  in  laryngitis,  285. 
Paralysis  crico-arytenoidei  postici,  511, 

in  domain  of  inferior  or  recurrent 
laryngeal  nerve,  506. 
Paralysis  in  domain  of  superior 

nerve,  505. 
Paralvsis  of  abductors, 

Plate  X.),  511. 
Paralysis  of  adductors,  bilateral  (Fig. 

Plate  X.),  508. 
Paralysis  of  arytenoideus,  508,  517. 

,,       of  crico-arytenoidei  laterales,  518. 
,,       of  the  sphincter  of  the  larynx  (Fig. 
98,  Plate  X.),  516. 
Paralysis  of  thyro-arytenoidei,  516, 

,,       of  arytenoideus  proprius  (Fig.  99, 
Plate  IX.),  517. 
Paralysis,  unilateral,  of  an  abductor  (Figs.  96 

and  97,  Plate  X.),  513. 
Parenchymatous  tonsilluis,  241. 
Parosmia  or  paraphresia,  625. 
Paroxysmal  sneezing,  567. 
Partial  extirpation  of  larynx,  493. 
Pathology  of  diphtheria,  343. 
,,        of  nasal  diseases,  532. 
,,        of  throat  diseases,  154. 
Perforation  of  palate,  206. 

,,         of  septum  narium,  590. 
Perichondritis  of  larynx,  311. 

,,  ,,       fibroid,  312. 

gouty,  318. 
),  ,,       strumous,  312. 

,,       syphilitic,  315. 
,,  ,,       traumatic,  313. 

>>  , ,       typhoid,  318. 

Pharyngeal  tenesmus,  223,  569. 

,,        tonsil,  hypertrophy  of,  522,  552, 
637,  670. 
Pharyngitis,  acute,  179. 

,,         atrophica,  193. 
chronic,  191. 

chronica  laterahs  hypertrophica, 

193. 

Pharyngitis,  membranous,  181. 
,,         cedematous,  183. 
,,         phlegmonous,  185. 
,,  ,,  follicular,  191. 

sicca,  193. 
,,         subacute,  190. 

suppurating,  184. 
„         ulcerative  septic,  187. 
Pharyngocele,  227. 
Pharyngotomy,  sub-lingual,  492. 
Pharynx,  abscess  of,  186,  227, 
,,       anajsthesia  of,  222, 

anatomy  of,  28. 
,,       deformities  of,  227. 
,,       dilatation  of,  227. 
,,       diseases  of,  177. 
,,       examination  of,  60. 
,,       foreign  bodies  in,  229. 
,,       glandules  of,  32. 
,,       herpes  of,  178,  182,  191. 
,,       hypennesthesia  of,  226. 
,,       lepra  of,  222,  443. 
lupus  of,  222,  435. 


Pharynx,  malformations  of,  227. 
„       morbid  growths  of,  228. 
motor  paralysis  of,  227. 
muscles  of,  31. 
neuralgia  of,  226. 
,,       neuroses  of,  222. 

new  formations  m,  228. 
paraesthesia  of,  223. 
scrofulous  ulceration  of,  212. 
,,       spasm  of,  225. 
,,       stenosis  of,  227. 
,,       syphilis  of,  congenital,  209. 
,,  ,,  primary,  200. 

,,  secondary,  201. 

,,  ,,  tertiary,  205. 

,,       tuberculous  ulceration  of,  213. 
,,       ulceration  of,  200. 
,,       varix  of,  193,  223. 
Phlebectasis  laryngea,  293. 
Photo-laryngoscopy,  72. 
Phthisis  of  pharynx,  213. 
Physical  signs  of  aural  diseases,  657. 

,,        ,,    of  throat  diseases,  96. 
Physiological  functions  of  nostrils,  538. 
Pigments,  formulae  for,  685. 

,,        internal,  124. 
Politzer  inflation,  673. 
Polypi,  aural,  676. 

,,     nasal,  543,  612,  670. 
Porte-caustique.  laryngeal,  129. 
Position  of  larynx,  as  a  symptorc,  97. 
Posterior  rhinoscopic  image,  85. 
,,       rhinoscopy,  80. 
,,       sesamoid  cartilages,  12. 
Post-nasal  catarrh,  635. 

,,  ,,       galvano-cautery  in,  637. 

,,  ,,       pharyngeal  abscess,  186. 

,,  ,,       vegetations,  522,  552,  637, 

670. 

Principle  of  laryngoscopy,  47. 
Proclivity  of  abductors  of  larynx  to  paralysis, 
513- 

Protector  for  cautery,  141. 
Ptomaine  theory  of  diphtheria,  336. 


Quinsy,  241. 


Q 


Ramoneur,  oesophageal,  142. 
Reflector,  laryngeal,  45. 
Registers  of  voice,  68. 
Removal  of  enlarged  tonsils,  256. 
Respiration  as  a  symptom,  89,  92. 

nasal,  as  a  symptom,  89,  94. 
Respirator  veil,  151. 
Respirators,  149. 

Respiratory  region  of  nose,  physiology  of, 
535- 

Retro-pharyngeal  abscess,  187. 
Rheumatism  and  tonsillitis,  242. 
Rhinitis,  acute,  557. 

atrophica,  543,  579,  670. 

caseosa,  588. 

croupous,  563. 

fibrinous,  564. 

hypercesthetic,  565. 

hypertrophica,  542,  571,  670. 

neurotic,  565. 

plastic,  564. 

purulent,  562. 
,,       specific,  562. 
,,       subacute,  564. 
Rhinoliths,  625. 
Rhinorrhagia,  622. 


GENERAL  INDEX. 


733 


Rhinorrhoea,  564. 
Rhinoscopic  image,  80. 

,,      posterior,  80,  85. 
Rhinoscopy,  anterior,  76. 

,,         posterior,  78. 
Rima  glottidis,  17. 
Rose  cold  (see  Nay  Fever),  544,  565. 
Rosenmiiller,  fossa  of,  87. 

S 

Sacculus  laryngis,  16. 
Santorini,  cartilages  of,  11,  66. 
Sarcoma  of  larynx,  468. 
Sarcomata,  nasal,  621. 
Scarification  of  larynx,  308. 
Scarlatinal  laryngitis,  282. 
Scirrhus  of  larynx,  468. 

,,      nasal,  621. 
Secretion  as  a  symptom,  90,  97. 
Semeiology  of  throat  diseases,  88. 
Sensation  of  larynx,  neuroses  of,  500. 
Septum  narium,  86. 

,,        ,,       abscess  of,  590. 
,,         ,,       deviation  of,  592. 

,,       haematoma  o',  589. 
,,         ,,       perforation  of,  590. 
Sequelae  of  diphtheria,  352. 
Sesamoid  cartilages,  anterior,  13. 

,,  ,,       posterior,  12. 

Sinus,  ethmoidal,  diseases  of,  551,  633. 

,,     frontal,  catarrh  of,  551,  633. 
Smell,  sense  of,  as  a  symptom,  89,  95. 
Snares,  laryngeal,  130. 

,,     nasal,  140. 
Soft  palate,  anatomy  of,  26. 

,,        examination  of,  57. 

in  tone-production,  71. 
Sore  throat,  aphthous,  178. 
,,  clergyman's,  191. 

gouty,  178. 

herpetic,  178,  182,  191. 
hospital,  185, 
membranous,  181. 
,,  oedematous,  184. 

,,  rheumatic,  178. 

,,  scorbutic,  178. 

,,  scrofulous,  212. 

,,  suppurating,  184. 

,,  syphilitic,  congenital,  209. 

,,       primary,  200. 
,,  ,,       secondary,  201. 

,,  ,,       tertiary,  205. 

,,  tubercular,  213. 

ulcerated,  200. 
,,  voice-users',  191. 

Spasm,  complete  glottic,  518. 
,,      of  pharynx,  225. 
,,     of  the  adductors  of  vocal  cords,  518. 
,,     of  the  glottis,  518. 
,,     of  the  tensors  of  vocal  cords,  517. 
Spasmodic  affections  of  larynx,  517. 
Specific  coryza,  562. 
Sphenoidal,  diseases  of,  551,  634. 

sinus,  diseases  of,  634. 
Sphincter  of  the  larynx,  paralysis  of,  516. 
Spirometer,  value  of,  98. 
Sponge-holders,  125. 

,,     probang,  132. 
Sporadic  diphtheria,  339. 
Spray,  nasal,  122. 
Spurious  croup,  323. 
Stenosis,  nasal,  objective  signs  of,  553, 
,,       ,,       subjective  signs  of,  554. 
,,     of  larynx,  388,  391. 
Stethoscopic  examination,  98. 
Strumous  perichondritis  of  larynx,  312. 


Subacute  laryngitis,  289. 
,,       pharyngitis,  190. 
,,       rhinitis,  564. 
Subjective  signs  of  aural  diseases,  651. 

,,    of  throat  diseases,  86. 
Sublingual  pharyngotomy,  498. 
Submucous  inflammation  of  larynx,  acute, 
300. 

Submucous  inflammation  of  larynx,  chronic, 
308. 

Summer  catarrh  (see  Hay  Fever),  544,  565. 
Suppuration  of  maxillary  antrum,  551,  626. 
Suppurative  catarrh  of  the  middle  ear,  676. 
Supra-glottic  division  of  larynx,  13. 
Surgical  therapeutics,  100. 
Synostosis,  nasal,  612. 
Syphilis,  hereditary,  209,  396. 
,,       lupoid,  441. 
,,       of  larynx,  congenital,  397. 
,,  tracheotomy  in,  394. 

,,       of  pharynx,  congenital,  209. 
,,  ,,       primary,  200. 

,,  ,,       secondary,  201. 

,,       tertiary,  205. 
Syphilitic    and    tuberculous    ulceration  of 

pharynx,  diagnosis  of,  219. 
Syphilitic  laryngitis,  380. 

,,       relapsing,  382. 

secondary,  380. 
,,       tertiary,  384. 
,,       ozasna,  579. 

perichondritis  of  larynx,  311. 
Syringe,  laryngeal,  112. 


T 

Table,  diagnostic,  of  aural  diseases,  656. 
Tampons,  nasal,  124. 
Taste,  sense  of,  as  a  symptom,  89,  95. 
Teeth,  examination  of,  57. 
Temperature  in  diagnosis,  98. 
Tenesmus,  pharyngeal,  223,  569. 
Tensors  of  the  vocal  cords,  spasm  of,  517. 
Teratomata,  naso-pharyngeal,  649. 
Testing  of  hearing-power,  651. 
Therapeutics,  deglutitory,  147. 
,,  dietetic,  147. 

,,  of  throat  diseases,  100. 

respiratory,  149. 
,,  vocal,  152. 

Throat,  anatomy  of,  6. 

,,  applications,  external,  it6. 
,,  ,,  internal,  124. 

,,     chronic  relaxed,  232. 
,,      consumption  of,  213,  399. 
,,     diseases,  atmosphere  in,  173. 

,,       climate  in  relation  to,  173. 
,,  ,,       clothing  in  relation  to,  175, 

dust  in  relation  to,  174. 
,,  ,,       general  etiology  of,  154. 

,,  ,,      pathology  of,  154. 

,,  ,,       semeiology  of,  88. 

, ,     examination  of,  37  ef  seq. 
hospital  sore,  184. 
massage  of,  141. 
,,      membranous  sore,  181. 
Thyro-arytenoid  nmscles,  20. 

paralysis  of,  516. 

Thyroid  cartilage,  7. 

Thyrotomy,  for  benign  neoplasms,  464. 

,,         for  malignant  neoplasms,  497. 
Tinnitus  aurium,  653. 
Tissue,  erectile,  of  nose,  536. 
Tone-production,  soft  palate  in,  71. 
Tongue-depressor,  56. 

examination  of,  58. 


734 


GENERAL  INDEX. 


Tonsil,  Luschka's  hypertrophy  of,  522,  552, 
637,  670. 

Tonsil,  pharyngeal  hypertrophy  of,  522,  552, 

637,  670. 
Tonsillar  abscess,  242. 
Tonsillitis,  acute,  241. 

,,       albuminuria  in,  247. 
,,       and  rheumatism,  243. 
,,       differential  diagnosis  of,  248. 
,,       follicular,  242. 
,,       lacunar,  242. 
,,       parenchymatous,  242. 
septic,  185,  241. 
Tonsillotomy,  256,  642,  648. 
,,  effects  of,  259. 

,,  haemorrhage  in,  257. 

,,  in  diphtheria,  368. 

Tonsils,  anatomy  of,  28,  239. 
,,       atrophy  of,  259. 
,,       benign  growths  on,  260. 

calcareous  concretions  in,  260, 
cancer  of,  261. 
,,       chronic  inflammation  of,  252. 
,,       discrete,  the,  58. 
,,       enlarged,  252. 

epithelioma  of,  264. 
,,       examination  of,  59. 
faucial,  156. 
histology  of,  239, 
laryngeal,  156,  271. 
.,       lingual,  156,  223. 
,,       lympho-sarcoma  of,  262. 
,,       mycosis  of,  260, 
,,       nasal,  536. 
,,       palatal,  156. 
,,       pharyngeal,  156. 
,,  ,,■         hypertrophy  of, 522, 552, 

637,  670. 
Tonsils,  physiology  of,  156. 
, ,       removal  of,  256. 
scirrhus  of,  262, 
tubal,  156. 
Tornwaldt's  disease,  552,  636,  671. 
Trachea,  23. 
Tracheotomy,  142. 

,,  in  acute  oedema,  308, 

in  benign  neoplasms,  465. 
in  congenital  syphilis,  397. 
in  croup,  331. 
in  diphtheria,  369. 
in  infra-glottic  oedema,  310. 
,,  in  laryngeal  phthisis,  424. 

,,  in  lepra,  444. 

,,  in  lupus,  440, 

,,  in  malignant  neoplasms,  490. 

in  oedema,  310. 
in  rhinoscleroma,  575. 
in  syphilitic  laryngitis,  394. 
in  tertiary  syphilis,  394. 
Traumatic  croup,  333. 

,,        perichondritis  of  larynx,  313. 
,,        uvulitis,  230. 
Tubercular  ulceration  of  fauces,  213. 

,,  mouth,  213. 

,,  ,,  pharynx,  213. 

Tuberculous  laryngitis,  398. 
Tuning-fork  as  a  test  of  hearing,  654. 
Turbinated  bones  and  bodies,  86. 


Turkish  baths  in  throat  diseases,  107. 
Tympanic  cavity,  examination  of,  660. 
Typhoid  fever,  laryngitis  in,  283. 
Typhus  fever,  laryngitis  in,  283. 

U 

Ulceration  of  pharynx,  200. 

,,    congenital  syphilitic,  209. 
,.  ,,    hereditary  syphilitic,  209. 

,,  ,,    primary  syphilitic,  200. 

,,  ,,    scrofulous,  212. 

,,  ,,    secondary  syphilitic,  201. 

,,  ,,    tertiary  syphilitic,  205. 

,,  ,,    tubercular,  213. 

Unilateral  paralysis  of  adductors  (Fig.  94, 

Plate  X.),  510. 
Upper,  thick,  registers,  69. 
Uraemic  symptoms  in  diphtheria,  344.  . 
Uvula,  abscission  of,  235. 

,,  ,,  in  diphtheria,  368. 

,,  ,,  in  pharyngitis,  183. 

,,     acute  inflammation  of,  231. 
,,     anatomy  of,  27. 
,,     angeioma  of,  238. 
, ,     cancer  of,  238. 
,,     chronic  inflammation  of,  232, 
,,     diseases  of,  231. 
,,     elongated,  232. 
,,     functions  of,  27. 
,,     haemorrhage  after  removal  of,  236. 
,,     malformation  of,  237. 
,,     new  growths  of,  237. 
,,     oedema  of,  231. 
,,     subacute  inflammation  of,  232. 
Uvulitis,  230. 

V 

Valsalvan  inflation  of  Eustachian  tube,  660, 
672. 

Vapour  inhalations,  104. 
Vapours  in  the  treatment  of  aural  disease, 
675- 

Varieties  of  benign  neoplasms  of  larynx,  452, 
454- 

Varieties  of  malignant  neoplasms  of  larynx, 
468. 

Variolous  laryngitis,  282. 
Varix,  lingual,  223. 

,,     of  pharynx,  193,  223. 
Venous  congestion  of  larynx,  272,  519. 
Ventricles  of  Morgagni,  16,  66. 
Ventricular  bands  (false  vocal  cords),  15,  66. 
Vertigo,  aural,  654. 
,,      laryngea  ,  522. 
,,      nasal,  565. 
Vocal  asynergy,  518. 

,,    cords,  spasm  of  tensors  of,  517. 
,,  16,66. 
Voice  as  a  symptom,  88,  91. 
Voice-users'  sore  throat,  191. 

W 

Watch,  the,  as  a  test  of  hearing,  652. 
Weight  as  a  symptom,  98. 
Wet  compress,  directions  for,  116. 
Wrisberg,  cartilages  of,  12,  66. 


THE  END. 


London  :  Baillierc,  Tindall  and  Cox,  King  IVilliam  Street,  Strand. 


